RatPack 2025-2026 Medical Info Form
This form should be filled out by a parent/guardian or with their assistance.

Note: this form collects the same information as the AAPS "Health Information Form for School Sponsored Trip/Camp" form. If you have a recent and up-to-date copy of that form from another activity, you can skip this form and instead email a copy of the AAPS form to us (830ratpack@gmail.com) or bring a paper copy to a meeting.

Returning members: If you filled this form out last year, we need to verify that this information is still up-to-date. The easiest way to do this is to fill out this form again. If you would rather reuse your information from last year, please email 830ratpack@gmail.com to request this. We will send any information we have from last year, and you will need to confirm that it is up-to-date in order to complete registration.

If you are unable to complete this form, please contact us directly so that we can find a solution, and also let us know if there are any allergies or medical conditions we should be aware of.
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Email *
Student first name *
Student last name *
Parent/Guardian name *
who is completing this form?
Parent/guardian email address
only if different from the person filling out this form
Medical Information
This helps us stay aware of any precautions we need to take
Medical/health history
select all that apply
Explaination of any conditions you selected above
  • for allergies, list allergens and indicate severity (e.g. if life-threatening)
  • for concussion/head injury, specify when this occurred
Do you have a religious objection to physician contact?
Clear selection
Date of last tetanus immunization
MM
/
DD
/
YYYY
Has the student been hospitalized in the past three months?
if yes, explain
if no, leave blank
Has the student had any recent operations or injuries?
if yes, explain
if no, leave blank
Medications
if applicable
Can the student carry/self-administer these medications?
if applicable
Clear selection
Additional conditions staff need to be aware of
if applicable - such as seasonal/environmental allergies, reactions to insect stings or bites, fainting, bed wetting, etc.
Health insurance information
AAPS requires this information.
Put "n/a" for any fields that your insurer does not provide.
Insurance company name *
Insurance policy/subscriber number *
Insurance group number *
Insurance phone contact number *
Any additional insurance information
only necessary if your insurer requires it
Submit
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