NASA C-3072 Emergency Medical Authorization

National
Aeronautics and
Space
Administration

Emergency Medical Authorization
Dropping In a Microgravity Environment (DIME)
(Completion of form is required for processing of application.)

Full legal name of student
Last name, suffix (e.g., Jr.)

Date of birth

First name

mm/dd/year
(e.g., 11/14/1992)

Middle name

Gender

Female

Male

Address

Home telephone number

Name of parent/legal guardian

Telephone number where parent or guardian can be reached between 8:00 a.m. and 5:00 p.m.

Name, telephone number(s), and relationship of other custodial parent or emergency contact.

Facts concerning the student's medical history to which the physical should be alerted:
Allergies
Medications taken

Physical impairments

Other

In the event that reasonable attempts to contact one of the parents of, or the legal guardian of, the above minor are not
successful, I hereby give my consent to the administration of medical treatment deemed necessary by the Medical Services
Office at the NASA Glenn Research Center. In the event that more extensive medical care is necessary than that given by
the Glenn Medical Services Office, I authorize the transfer of the minor to a local hospital by ambulance.

Signature of parent/guardian

NASA C-3073 (NOV 10)

Date