WorldStrides Emergency Medical Release

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Please complete the following information for the Gwendolyn Brooks Springfield Trip on April 17, 2020.

Student's First Name *

Student's Last Name *

Student's Birthdate *

YYYY

Street Address, City, State, & Zip *

Home Phone Number *

Father's Name (N/A if it doesn't apply) *

Father's Email (N/A if it doesn't apply) *

Father's Contact Number (N/A if it doesn't apply) *

Mother's Name (N/A if it doesn't apply) *

Mother's Email (N/A if it doesn't apply) *

Mother's Contact Number (N/A if it doesn't apply) *

Student's Medical and/or Food Accommodations (N/A if it doesn't apply) *

Last Tetanus Shot *

Other Medical Conditions *

Medication being used (include dosage/frequency) *

Participant's present state of health *

Good

Fair

Poor

Required

Family Physician Name *

Family Physician's Contact Number *

Medical Insurance Company *

Policy Holder's Name *

Medical Insurance Contact Number *

Policy Number *

Authorization for Treatment of Minor

I, the undersigned, understand and acknowledge that reasonable efforts will be made to contact the parents in case of an emergency, and, if possible, before any medical treatment is administered. In the event of an emergency or if the parents cannot be notified, I hereby give permission to the Program Leader or the WorldStrides staff to secure treatment for my child. If necessary, this includes selection of physicians and medical treatment facility who are then authorized to perform such treatments as deemed medically necessary. I further give my permission for WorldStrides staff to have access to medical records relating to any treatment contemplated or received by my child and to provide such information, as necessary, to health insurance carriers.

WorldStrides cannot be responsible for accommodating any food allergies, requirements or restrictions and is not responsible for any problems associated with the same. All issues with regard to food and drink, including allergies, requirements and restrictions are the sole responsibility of the participant.

In the event of any emergencies during the trip, the undersigned hereby grants authority to be exercised at the discretion of the Program Leader or chaperone to dispense over-the-counter medication.

Today's Date *

YYYY

Parent Consent (Type First and Last Name) *

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