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

Source: http://www.trekla.net/signup/index_htm_files/Trek%20LA%20Emergency%20Medical%20Form.pdf