Student Medical Information Form - Short printable pdf download

Teton Science Schools

ADULT/STUDENT MEDICAL INFORMATION

Short Form

Program Name(s)

Program Date(s)

All information on this form must be complete, including signatures, prior to participation.

Include names/dates of all programs attending.

General Participant Information

This information will be shared only with Teton Science Schools (TSS) personnel, consulting and treating medical personnel and other

individuals working with TSS. Otherwise the information will remain confidential.

Name

Date of Birth

Mailing Address

City

State

Zip Code

Phone Number

Email Address

In case of emergency, what relative, neighbor or friend should be called?

Name

Relationship

Phone #

Pre-Existing Conditions

Do you have a pre-existing medical condition that might affect your participation in an active outdoor program? If yes,

YES

please describe this condition below.

______________________________

Medications/Allergies

Are you currently taking any medication? If yes, what type, dosage and medical condition? If more space is needed, attach a

YES

separate sheet.

Are you allergic to any medications, foods or environmental stimuli (bee stings, etc.)? If yes, please explain below.

YES

Optional

Each participant is responsible for his/her own medical expenses.

Health Insurance Provider

Policy Number

Phone _____________________

Physician _______________________________________________

Phone _________________________

Participant or Parents/Legal Guardians (“parents”) of Minor Participants – Medical Authorization and

Permission

I authorize TSS staff, contractors or other medical personnel to obtain or provide medical care for me/my child, to transport me or my

child to a medical facility and to secure treatment (including but not limited to routine or emergency health care, hospitalization,

injection, anesthesia or surgery) they consider necessary for my/my child's heath. I agree to pay all costs associated with that care and

transportation and agree to the release (to or by TSS) of any medical records necessary for treatment, referral, billing or insurance

purposes. Note to parents of minor participants: except to the extent limited by this form, my child has permission to participant in all

TSS activities. I authorize that all information on this form is accurate and complete and I have not withheld any information.

For participants under the age of 18 yrs. (minors): Participants over the age of 12 yrs. AND one or preferably both parents of minor

participant must sign this form.

Participant Signature (parents may print the name for those participants under 12 yrs. old) Date

Print name here

Parent 1

/Parent 2

Parent or Legal Guardian Signature Date

Print name here

/Parent or Legal Guardian Signature

Date

Print name here

Short Risk Release Form 6/1/06

Student Medical Information Form - Short

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