Middle School 2021-2022 Medical Emergency Form

This is confidential. Please Sign and Return.

Participant Information:
Participant Name*

First NameLast Name
Middle School StudentHigh School StudentTeacherParentAdultOther
Birthdate*

MonthDayYear
Date
School (if applicable)
February 18-25, 2022 (High School)March 25-April 1, 2022 (High School)March 12 - March 18, 2022 (Middle School)
Social Security #: (Optional)
YesNoOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts - Parent/Guardian 1 - First Name
Last Name
Work Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Parent/Guardian 2

First NameLast Name
Work Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Another responsible adult who can be contacted in an emergency in case the above are not available:
Name*

First NameLast Name
Cell Phone or best phone to contact*
Format: (000) 000-0000.
Relationship*
Participant Medical Insurance: Medical Provider*
Phone*
Format: (000) 000-0000.
Medical Coverage Carrier*
Name of Insured*
Medical ID #*
Group ID #*
Health History: Describe any health conditions that could become an emergency, such as asthma, diabetes, panic attacks and etc. List medications and current dosages on page two. SEND medications with your child.*
Please list the reason(s) if participant has visited a health care provider in the past six months. What was the outcome and what if any medication(s) and/or treatments was prescribed?*
YesNo
If yes, Last visit was:
Are there any health conditions which may require special accommodations or needs?
Please list any dietary restrictions - be specific (vegetarian, no pork, gluten free, etc.)*
Food allergies*
Medication allergies*
List all other allergies
If medically needed or currently used, please pack your child's inhalers, EpiPen, insulin etc.
IbuprofenGas-XNyQuilMidolRobitussinDayQuilDramamine/BonineClaritinTylenol ESPepto-BismolBenadrylMagnesium CitratOther
Please list all prescription medications that participant is currently taking. Please include the Medication Name, the Dose, and the Frequency. *
In the event of an emergency during the journey, the parents/guardians, by signing this form, hereby gives permission to the physician/nurse selected by the Sojourn staff to hospitalize and/or provide/secure proper treatment including but not limited to injection, anesthesia or surgery for the child listed below.

Covid Policy:

1.     All Sojourn to the Past participants/travelers must be vaccinated. *

Prior to meeting number four, all participants will need to submit a copy of their vaccination card, along with their medical form.

2.     If a participant is diagnosed with COVID-19 prior to travel and with insufficient time to meet quarantine requirements, Sojourn will refund all portions of the cost that are refundable to Sojourn. For example, if airfare has been paid and is nonrefundable, then that portion will not be refunded.

3.     If a traveler is diagnosed with COVID-19 while on the trip, they (the parents/guardians) will assume the cost and responsibility of caring for the participant as well as transportation back to their home.
Please upload a picture or scan of your vaccination card. *

Cancelof
Full Name*
Date*

MonthDayYear
Date
Signature (Parent or Legal Guardian if under 18)*

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