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Get UConn Pre-College Summer Health History And Consent For Treatment 2019-2024

May be typed on, or handwritten. Then, once completed and signed, upload to the student s enrollment profile. A completed form includes all information mentioned below, including hand signatures from both the parent/guardian and participant. For questions regarding this form contact UConn Pre-College Summer at (860) 486-0149 or at pcs uconn.edu PARTICPANT LAST NAME: PARTICIPANT FIRST NAME: MIDDLE INITIAL: DATE OF BIRTH: / / HOME PHONE: BIRTHPLACE/COUTNRY OF CITIZENSHIP: HOME A.

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