February 26th - March 2nd Medical Emergency Form

This is confidential. Please Sign and Return.

Participant Information:

Participant Name *

First Name Last Name

How would you like your name displayed on your name tag?

First Name Last Name

Type of Participant *

SFPD Pepperdine Other

Birthdate *

Date

Social Security #: (Optional)

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Emergency Contact #1

First Name Last Name

Work Phone

Cell Phone

Relationship *

Emergency Contact #2

First Name Last Name

Work Phone

Cell Phone

Relationship *

Participant Medical Insurance: Medical Provider *

Phone *

Medical Coverage Carrier *

Name of Insured *

Medical ID # *

Group ID # *

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

In the event of an emergency during the journey, 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. Sojourn Project cannot be held responsible if any participant on the trip is infected with COVID-19. All Sojourn to the Past participants/travelers must be double vaccinated at least two weeks before trip. *

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 will be required to quarantine according to CDC guidelines and will be responsible for any airline change fees for their flight and additional nights at hotel they are quarantined at.

Please upload a picture or scan of your vaccination card. *

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Date *

Date

Signature *

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