2018-2019 Campus Life Medical Information
This form is to cover all medical information for your high school student. Once this form is completed, your student will be covered for all trips and events with Lansing Campus Life from September 1, 2018 to August 31, 2019.

For our bigger trips (Big Chill, Florida Spring Break, Smokies, Wisconsin Dells, etc.), a packing list and an information sheet will be sent to your occupancy.

Campus Life will only use this medical information in cases of emergency.

If your medical information changes during the year, please return to this page and update your information.

* THIS FORM MUST BE COMPLETED BEFORE YOUR STUDENT CAN PARTICIPATE IN ANY CITY-WIDE CAMPUS LIFE EVENT OR TRIP!

** Some events or trips hosted by an individual or combined club(s) will require your student(s) to have this form completed. That is up to the discretion of the Executive Director, Trent Bushnell, and/or the school's club director.

Are you filling this information out for the first time or updating? *
Student's Name (First and Last): *
Your answer
School *
Gender *
Student's Address *
Your answer
City *
Your answer
ZIP Code *
Your answer
Insurance Co. *
If none, type none.
Your answer
Policy # *
If none, type none.
Your answer
Any Medical Conditions? *
If none, type none.
Your answer
Any Medications that must be taken? *
If none, type none.
Your answer
Any Allergies? *
If none, type none.
Your answer
EMERGENCY CONTACT *
Your answer
Relationship *
Your answer
Emergency Contact's Phone Number *
Your answer
Parent/Guardian's Phone Number
If different from Emergency Contact's Phone Number.
Your answer
Reminders for Registering for Trips
This form is to cover medical information for your high school student from September 1, 2018 to August 31, 2019. Unless your medical information changes during that time, we require that you fill out this information only once per year.

Please note that in order to be signed up for a trip or an event with Campus Life, this form, the trip's or event's permission slip, and the required payment must be submitted in order to save your student's spot.

Payments & Permission Slips can be completed online at www.lansingcampuslife.net.

Checks can be made out to Lansing Campus Life and sent to:
5222 Dumond Ct.
Lansing, Mi 48917

Parent Signature *
Your answer
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