Form 1427 Authorization for Treatment of Field-Team Member/Partici

NATIONAL SCIENCE FOUNDATION
4201 WILSON BOULEVARD
ARLINGTON, VIRGINIA 22230

OFFICE OF POLAR PROGRAMS

AUTHORIZATION FOR TREATMENT OF FIELD-TEAM
MEMBER/PARTICIPANT UNDER THE AGE OF 18 YEARS

I am the parent or guardian of ____________________, who is an under age participant in the United States
Polar Programs. Should any medical/dental care be required during his or her deployment to Antarctica or to
the Arctic, I hereby give my authorization and consent to the United States Polar Program’s medical care
provider(s) for any medical care, treatment or procedures that are deemed medically necessary while my son or
daughter is deployed to either the Arctic or the Antarctic.

______________________________________
Name of Parent or Guardian

______________________________________
Signature and Date

Address________________________________________________________________________________
________________________________________________________________________________
Telephone Numbers: Daytime: _____________________

Evening: _________________________

NSF Form 1427
Page 1 of 1 (APR 2002)
Original plus one: Contractor Medical Staff
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010

Applicants: Please retain one copy for your records