Emergency & Medical Information Form

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

Student Information

Student's Name(Required)

First Middle Last Suffix

Date of Birth(Required)

Age(Required)

Gender(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Information

1st Parent/Guardian name(Required)

First Middle Last Suffix

Relationship to Student(Required)

1st Parent/Guardian email(Required)

1st Parent/Guardian Cell Phone(Required)

1st Parent/Guardian Home Phone

1st Parent/Guardian Work Phone

Address(Required)

Street Address Address Line 2 City State ZIP Code

2nd Parent/Guardian name

First Middle Last Suffix

Relationship to Student

2nd Parent/Guardian email

2nd Parent/Guardian Cell Phone

2nd Parent/Guardian Home Phone

2nd Parent/Guardian Work Phone

Address, if different than above

Street Address Address Line 2 City State ZIP Code

Other Emergency Contacts in U.S.

Physician(Required)

Physician's Phone Number(Required)

Name

Relationship

Phone Number

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)