USC Aiken :Parent/Guardian/Student Information Form

Department of Athletics
University of South Carolina Aiken
471 University Parkwa
Aiken, SC 29803

This form is to be complete by the Parents, Guardians, or the student

Note: Complete all blanks in this form. Failure to complete all blanks could result in claims processing delays.
If information is not applicable, indicate the reason it is not appllicable (e.g. deceased, divorced, unknown).

Name of Athlete: Sport:

Social Security No or Passport No: Date of Birth:

College Address: College Phone:

City: State: Zip:

Home Address: Home Phone:

City: State: Zip:

FATHER/GURADIAN INFORMATION

Father's Name:

Social Security No:

Date of Birth:

Address:

City: State: Zip:

Telephone:

Employer:

Address:

City: State: Zip:

Telephone:

Medical Insurance

Company or Plan:

Address:

City: State: Zip:

Policy Number:

Telephone:

Is this plan an HMO or PPO? (Place a "y" for yes, an "n" for no):

Is pre-authorization required to obtain treatment? (Place a "y" for yes, an "n" for no):

Is a second opinion required before surgery? (Place a "y" for yes, an "n" for no):

MOTHER/GURADIAN INFORMATION

Mother's Name:

Social Security No:

Date of Birth:

Address:

City: State: Zip:

Telephone:

Employer:

Address:

City: State: Zip:

Telephone:

Medical Insurance

Company or Plan:

Address:

City: State: Zip:

Policy Number:

Telephone: