Microsoft word - trek la emergency medical form.doc
Medical Form and Emergency Contacts Child’s Name______________________________________ Date of Birth___________________ Address__________________________________City____________________Zip______________ Mother’s Name______________________________ Home #___________________ Work #_________________ Cell #____________________ Father’s Name_______________________________ Home #_____________________ Work #_____________________ Cell #____________________ In Case of Emergency please contact: Name______________________Phone_________________ Relationship______________ Name______________________Phone_________________ Relationship______________ Name______________________Phone_________________ Relationship______________ Health Care Information Insurance Provider__________________ Policy#________________________________ Phone: ___________________________________________________________________ Doctor_____________________________ Phone #_______________________________ Any additional medical information_____________________________________________ _________________________________________________________________________ Medical History Has your child had any of the following (Please indicate the most recent dates):
Mumps__________ Measles__________ Headaches______________
Tonsillitis________ Fainting__________ Nosebleeds______________
Does your child have any condition that would prevent him/her from participating in any activities?
__________________________________________________________________________________
__________________________________________________________________________________
Medical Form and Emergency Contact Information Trek LA Page 1 of 2
Please provide details of any of the following ailments (if applicable):
Allergies (food, drugs, etc.)____________________________________________________________
Bee Stings, Mosquitos________________________________________________________________
Asthma or Hay Fever_________________________________________________________________
Serious Injuries/Illnesses______________________________________________________________
In addition, please describe the reaction if exposed to any allergens, the severity of the reaction, and the requested course of action: _________________________________________________________ Does your child require an EpiPen? Yes: _______ No: ____________
Has your child received medical treatment during the past year? Yes:
Date: _____________ Reason: ____________________________________________
Does your child currently take medication? ___________________________________________ If Yes, please list medications: ______________________________________________________
Will your child require any medication while at camp? Yes: ________ No: ___________
Is your child up-to-date on all state required immunizations? _________________________________
Please provide the date of your child’s last tetanus shot: ____________________________________
Please check the non-prescription medications that we have permission to give your
Pepto Bismol ____ Throat lozenges _____ Tylenol ______
Benadryl ______ Dramamine ______ Advil _______
I hereby give Trek LA permission to administer medications indicated on this form and Trek LA is held harmless. Incase of an emergency and I cannot be reached, I authorize Trek LA director or her designee, to obtain medical treatment that he or she deems necessary for the welfare of my child or ward.
Parent/Guardian Name____________________ Relationship _________________ _______________
Medical Form and Emergency Contact Information Trek LA Page 2 of 2
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