Medical Information Form
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Student Name (first & last) *
Student Birth Date *
MM
/
DD
/
YYYY
Student Age
Student Email Address *
Student Phone Number *
Parent/Guardian #1 Name (first & last) *
Parent/Guardian #1 Email Address *
Parent/Guardian #1 Phone Number *
Parent/Guardian #2 Name (first & last) *
Parent/Guardian #2 Email Address *
Parent/Guardian #2 Phone Number *
Primary Care Physician (or similar) Name
Primary Care Physician (or similar) Phone Number
Medical Insurance Information
List and describe any allergies, medical conditions, or special needs of your child. Note especially any known allergies to foods or insect stings. List any medications your child is currently taking with any special information or instructions. Add any additional information that we should know. If none, write "none." *
Permission For Emergency Medical Treatment: I hereby give my permission for non-prescription medication (for example, Tylenol) to be given to my child if deemed necessary by designated trip leaders. In case of surgical emergency, I hereby give permission to the physician selected by the leader, or in his/her absence, a designee, to hospitalize, secure treatment for, and to order injections, anesthesia, or surgery for my child as named above. Any directions to the contrary should be specified.
Authorization: By typing your name below you are "signing" this medical form. *
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