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EMERGENCY CONTACT and HEALTH INFORMATION (OVERNIGHT TRIP) Form #2
PLEASE PROVIDE THE MOST CURRENT AND UP TO DATE EMERGENCY CONTACT INFORMATION FOR YOUR CHILD
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* Indicates required question
Email
*
Your email
Student's First Name (As written on legal documentation)
*
Your answer
Student's Last Name (As written on legal documentation)
*
Your answer
Student Gender
*
Male
Female
Student's Date of Birth
*
MM
/
DD
/
YYYY
Parent/Guardian and Emergency Contact Information:
Parent/Guardian #1: Name
*
Your answer
Parent/Guardian #1: Home, Cell, and Work Phone Numbers
*
Your answer
Parent/Guardian #2: Name
*
Your answer
Parent/Guardian #2: Home, Cell, and Work Phone Numbers
*
Your answer
Emergency Contact: Name
*
Your answer
Emergency Contact: Relationship to Student
*
Your answer
Emergency Contact: Home, Cell, and Work Phone Numbers
*
Your answer
Health Insurance and Prescription Information:
Student Health Insurance Information: Company and Policy #
*
Your answer
Student Prescription Insurance Information: Company and Policy #
*
Your answer
IMPORTANT: Digital Scans of your insurance card(s), both front and back, are required.
If your Health Insurance card is also used as your prescription card, please make note of this when your child submits the Digital Scans.
PARENT ELECTRONIC SIGNATURE, acknowledging the Emergency Contact Information is complete to the best of my knowledge. By selecting the "YES" checkbox, you are signing this Agreement Electronically.
PARENT ELECTRONIC SIGNATURE
*
YES
HEALTH INFORMATION
Completion of this information is required for all students attending an overnight trip. Updated information is required if there are new health concerns prior to the time of the trip.
#1 Please Select each item that may apply to your child
*
Asthma
Diabetes
Heart Condition
Rash
Mobility Issue
Epilepsy
Allergies
Other
None Apply to my Child
Required
IF you indicated a response to any of the above, please explain below. IF answering for allergies, please state what your child is allergic to, the type of reaction, and how you usually treat it.
Your answer
#2 Did your child have any recent illnesses or injuries that the trip sponsors/chaperones/nurses should be aware of?
*
YES
NO
IF you answered yes, please explain
Your answer
#3. Is Medication (either Over-the-Counter and/or Prescribed) required for your child?
*
YES
NO
IF medication is required, please list the medication(s) below and fill out the more detailed "Medication Authorization" form. All medications, including over-the-counter medication, must be prescribed by your physician.
Your answer
#4 This Medical and Health information form is completed to the best of my knowledge.
*
YES
PARENT ELECTRONIC SIGNATURE, acknowledging the Health Information form is complete to the best of my knowledge. By selecting the "YES" checkbox, you are signing this Agreement Electronically.
PARENT ELECTRONIC SIGNATURE
*
YES
A copy of your responses will be emailed to the address you provided.
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