Medical Information
GERMAN EXCHANGE 2024
List all major and minor medical issues that the Trip Leader and Chaperones should know about to ensure all participants have a safe and orderly trip (e.g. motion-sickness, seizures). This includes emotional and psychological concerns.
Name of Parent/Guardian Completing this form:
*
First Name
Last Name
Email of Parent/Guardian Completing this form:
*
example@example.com
Child's Name:
*
First Name
Last Name
Condition(s):
*
Allergies (Include Food):
*
Medications and Dosage Amounts:
*
Name of Prescribing / Treating Physician
*
Doctor's First Name
Doctor's Last Name
Other Special Needs (Include Dietary Needs if any):
*
Signature
*
Submit
Submit
Should be Empty: