Participant Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Participant Medical Information
Does the student have any chronic medical conditions (e.g., heart defects, thyroid issues, etc.)?
*
Yes
No
If yes, please describe:
Does student take any medications?
*
Yes
No
If yes, please list all medications:
Does the student have any allergies (food, medication, environment)?
*
Yes
No
If yes, please describe:
Does the student have any dietary restrictions or special dietary needs?
*
Yes
No
If yes, please describe:
Does the student have a history of seizures?
*
Yes
No
If yes, please describe:
Does the student require assistance with mobility or use aids?
*
Yes
No
If yes, please describe:
Does the student have any behavioral considerations or triggers?
*
Yes
No
If yes, please describe:
Any other information to ensure participant's safety and well-being?
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Consent and Authorization: I authorize trip organizers to provide necessary care and contact emergency services if needed.
YES
NO
Signature of Parent/Guardian/Caregiver
Full Name of Parent/Guardian/Caregiver:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
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Should be Empty: