2023 Medical Emergency Form

This is confidential. Please Sign and Return.

Participant Information:
Participant Preferred Name*
First and Last Name
Participant Legal Name*

First NameLast Name
Type of Participant*

Middle School StudentHigh School StudentTeachersParentAdultOther
Birthdate*

MonthDayYear
Date
School (if applicable) *
ex: Woodside, Taylor, Sequoia, Westmoor
Sweatshirt Size*
What Trip are you attending?

February (High School)March (High School)March (Middle School)
First trip / flight alone?*

YesNoOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts - Parent/Guardian 1 - First Name*
Last Name*
Email*
example@example.com
Work Phone*
Cell Phone*
Parent/Guardian 2*

First NameLast Name
Work Phone*
Cell Phone*
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*
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?*

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.
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).*

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 nurse to act on the best interest of the child.

Covid Policy:

1. 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.

2. 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.
Full Name*
Date*

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

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