Travel Medical Form - Spanish Exchange (March 2025)
A parent or guardian must complete and sign this form.
Name of Parent/Guardian Completing this Form
*
First Name
Last Name
Email of Parent/Guarding Completing this Form
*
example@example.com
Child's Name
*
First Name
Last Name
Emergency Contact Information
Emergency Contact - Primary
*
First Name
Last Name
Relationship to Child
*
Mother, Father, Grandparent, etc.
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact - Secondary
*
First Name
Last Name
Relationship to Child
*
Mother, Father, Grandparent, etc.
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact If Parents/Guardians Cannot Be Reached
*
First Name
Last Name
Relationship to Child
*
Mother, Father, Grandparent, etc.
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Medical Information
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.
Conditions(s):
*
Allergies (Include Food):
*
Medications and Dosage Amounts:
*
Name of Prescribing/Treating Physician:
*
Provider's First Name
Provider's Last Name
Other Special Needs (Include Dietary Needs if any):
*
Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: