2019East Coast Tour
Health Information Form

Please fill out the form completely

Student's First Name

Student's Last Name

Date of Birth

Persons to call in case of emergency:

EMERGENCY CONTACT 1

Emergency Contact Name

Relationship to Student

Cell Phone

Work Phone

EMERGENCY CONTACT 2

Emergency Contact Name 2

Relationship to Student

Cell Phone

Work Phone

EMERGENCY CONTACT 3

Emergency Contact Name 3

Relationship to Student

Cell Phone

Work Phone

Are there any health problems that may affect your student during the trip? If so, please specify:

Will your child have any medications in their possession on the trip?

Yes

List any allergies to medications:

Does the chaperone in charge have your permission to administer over-the-counter medications for minor ailments(such as headaches, upset stomachs, rashes, cuts, etc.) to your child?

Yes

Name of Insurance Company

Insurance Phone Number

Insurance Policy Number

Insurance ID Number

Please have your student submit a copy of your medical insurance card before the trip**

Medical Treatment Release:
I give my permission as parent/guardian of the above listed minor to procure emergency medical care for my child due to accident or illness in the event that, in the opinion of the teacher/tour chaperone, it becomes necessary. Such care may be procured without further consent of either of us. I agree to be solely responsible for the payment of any costs not covered by insurance accrued in the process of aiding my child.

Name of Parent/Guardian

2019East Coast Tour Health Information Form

Please fill out the form completely

2019East Coast Tour
Health Information Form