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

Birthdate

Date

School (if applicable)

ex: Woodside, Taylor, Sequoia, Westmoor

Sweatshirt Size

What Trip are you attending?

First trip / flight alone?

Other

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

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?

Is the participant receiving any mental health services?

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 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

Signature (Parent or Legal Guardian if under 18)