Authorization for Emergency Medical Treatment

Authorization for Emergency Medical Treatment needs to be completed by the parents (guardians). Please print or type in capitals. The functions of the agreement are listed below:

A / In case of medical emergency of the student and need for emergency treatment, MingChuanUniversity will try to notify parents (guardians) or person listed on the agreement as an emergency contact.
B / In case of a medical emergency concerning the student, at a time when the parents (guardians) or listed emergency contacts, for any reason, cannot be reached, the school and its employees have the full power to act on parents (guardians) or the student’s behalf for the following treatments:
1. Administer first aid;
2. Authorize a medical doctor to examine or treat my child;
3. Arrange for the transportation of my child, whether by ambulance or otherwise, to a proper facility where emergency medical treatment is normally administered, including but not limited to, an emergency room of a hospital, a doctor’s office, or a medical clinic;
4. Sign releases as may be required in order to obtain any medical or surgical treatment as is required in the judgment of medical authorities at the facility
C / Please note:
1. Before departure, students should prepare the document and have it signed by the parents (guardians), and then bring the document for the Registration at MCU.
2. Please print or type in capitals.
D / Contact Information
International Student Advising Office
Tel: +886-3-350-7001 ext. 3611, 3311
Fax: +886-3-359-3854
E-mail:
Off-Campus & Overseas Students’ Service Section
(Taipei Campus)
Tel:+886-2-2882-4564 ext. 2215
Fax:+886-2-2880-5783
E-mail:

I, ______[name of parent/guardian], understand that in the case of emergency of my child,______[name], MingChuanUniversity at 5 De-Ming

given name / family name given name / family name

Rd.,GweiShan, Taoyuan,Taiwan will try to notify me or the person I have listed below as an emergency contact. In case of a medical emergency concerning my child, at a time when I or my listed emergency contact, for any reason, cannot be reached, I hereby grant with full power to MCU and its employees to act on my or my child’s behalf the following treatments: 1. Administer first aid; 2. Authorize a medical doctor to examine or treat my child;3. Arrange for the transportation of my child, whether by ambulance or otherwise, to a proper facility where emergency medical treatment is normally administered, including but not limited to, an emergency room of a hospital, a doctor’s office, or a medical clinic; and 4. Sign releases as may be required in order to obtain any medical or surgical treatment as is required in the judgment of medical authorities at the facility. I hereby agree to accept the financial responsibilities for any cost thus incurred in the treatment of any illness, accident. I further agree that in the process of seeking or providing such treatment, neither Ming Chuan University nor its employees shall be liable, de facto or de jure, for any complications that may arise thereof.

The following personsare appointed as my/our child’s Emergency Contact (if I/we cannot be reached):

1. Name ______Phone Numbers: Home)______Office) ______Cell) ______

2. Name ______Phone Numbers: Home)______Office) ______Cell) ______

3. Name ______Phone Numbers: Home)______Office) ______Cell) ______

______

Signature of Parent/Guardian

______

Printed name of Parent/Guardian

Phone Numbers:Home)______Office)______Cell)______Date: ______

The authorization comes into force upon legally-binding signature.

This information will be kept confidential in the possession of the university. Should the need arise, this information may be given to the proper medical authorities.

本表單蒐集之個人資料，僅限於交換學生申請目的存續期間所需之必要範圍與地區內，供業務相關人員處理及利用。您將享有個資法第3條規定的五項權利，並可至「銘傳大學個人資料保護專區」(

*The information collected on this form is only used in the range and region required for the purposes of holding administrative processing and data analysis for exchange student application; the period of keeping the information on file is based upon the activity. You will have rights in accordance with Item 5, Article 3 of Personal Information Protection Act. Please refer to MCU Guidelines for Personal Information Protection Management and MCU Personal Information Management System at URL ( for further understanding of MCU personal information management policy, regulations and contact information.