Disneyland Medical Information

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First Name *

Middle Name

Last Name *

Email Address *

Medical Care Card Number *

Travel Insurance Company *

Travel Insurance Policy Number *

Birthdate *

YYYY

Gender *

Please Check all Medical Conditions *

None

Eating Disorders Anorexia or Bulimia

Hay Fever

Headaches

Anxiety Issues

Bed Wetting

Asthma

Diabetes

Epilepsy

Ear Infections

Other:

Required

List Any Allergies to Drugs or Food (Put None if there aren't any) *

Authorization *

The health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted by me.

In the event of an emergency, after an effort has been made to contact the parents, guardian or those listed as the emergency contacts, I hereby give permission to the physician selected by Steve Swaddling or designated chaperone to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child.

Your signature indicates you have completed the information correctly and to the best of your knowledge.

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