Emergency & Medical Information Form

Emergency & Medical Information Form (completed by Parent/Guardian)

Youth Information

Youth's Legal Name(Required)

First Middle Last Suffix

Preferred name or nickname

Date of Birth(Required)

Age(Required)

Gender(Required)

Parent/Guardian Information

Name of parent/guardian completing this form(Required)

Emergency Contacts besides parent(s)/guardian(s)

Physician(Required)

Physician's Phone Number(Required)

Name(Required)

Relationship(Required)

Phone Number(Required)

Name

Relationship

Phone Number

Student Medical/Health Information

Age(Required)

Blood Type(Required)

Height(Required)

Weight(Required)

Allergies: medicines (generic), anesthetics, foods, etc…(Required)

Other dietary restrictions:

Medical condition(s) to be taken into account in the event of an emergency:(Required)

Prescription medication(s) taken on a regular basis (Please list by name, dosage, and reason):(Required)

Medical history (Please list serious injuries/ illness/ hospitalizations and dates):(Required)

Vaccination History

Below are the generally recommended vaccinations for participants from the U.S. traveling to France or Germany according to the CDC travel website: http://wwwnc.cdc.gov/travel/destinations/list. For each below, list # of shots & Date of last shot.

Diphtheria, Tetanus, Pertussis (DTP, DTaP, DT, Tdap, or Td)

Polio (IPV, OPV)

Chickenpox (Varicella) or date of disease or Serological Confirmation of Varicella Immunity

Measles, Mumps, Rubella Vaccine (MMR vaccine) (Or list individual immunizations or date of disease or Serological Confirmation of immunity)

Influenza (list latest date only)

Covid-19 (list latest date only)

Hepatitis A Vaccine

Hepatitis B Vaccine (HBV)

Insurance

Name of Insurance Company(Required)

Policy holder Name(Required)

ID #(Required)

Group #(Required)

Signature of Parent / Legal Guardian (Typed)(Required)

Date(Required)

Emergency & Medical Information Form