Medical Information Form

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This form should be completed with the participant & parent/guardian present. After we receive your completed form, we will schedule a phone call with you and your parent/guardian to review the information provided.

This medical form is confidential and will only be viewed by ITE Staff. Over the years, many students with a variety of medical/psychological challenges have successfully participated in our programs, however we must be aware of medical conditions in order to offer quality care and support. Failure to disclose such information could result in serious harm to you or fellow participants.

Email *

PARTICIPANT INFORMATION

Full Name *

First & Last Name

Pronouns (optional)

Birthdate *

YYYY

School *

Current Grade Level *

Sex Assigned at Birth (optional)

Ex. Male, Female, Intersex

Phone Number *

If participant does not have their own phone, write "N/A"

Home Street Address *

Ex. 4227 W. 7th St.

Home City, State & Zip Code

Ex. Tucson, AZ 84729

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