Middle School 2021-2022 Medical Emergency Form

This is confidential. Please Sign and Return.

Participant Information:

Participant Name *

First Name Last Name

Type of Participant *

Middle School Student High School Student Teacher Parent Adult Other

Birthdate *

Date

School (if applicable)

What Trip are you attending? *

February 18-25, 2022 (High School) March 25-April 1, 2022 (High School) March 12 - March 18, 2022 (Middle School)

Social Security #: (Optional)

First trip / flight alone? *

Yes No Other

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Emergency Contacts - Parent/Guardian 1 - First Name

Last Name

Work Phone

Cell Phone

Parent/Guardian 2

First Name Last Name

Work Phone

Cell Phone

Another responsible adult who can be contacted in an emergency in case the above are not available:

Name *

First Name Last Name

Cell Phone or best phone to contact *

Relationship *

Participant Medical Insurance: Medical Provider *

Phone *

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? *

Is the participant receiving any mental health services? *

Yes No

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.

Check all over the counter medications participant may take if needed. Medications must be listed in order to be administered on the journey (for students). *

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. *

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Full Name *

Date *

Date

Signature (Parent or Legal Guardian if under 18) *

Clear