Field Trip Health Form printable pdf download

Field Trip Health Form

FIELD TRIP HEALTH FORM

(Mandatory for student and multi-day adult participants)

Trip Date __ / __ / __

Participant Name: __________________________ ____________________________

Last

First

Age: ____

Sex: F / M

Home Phone: (

) ________________

Home Address: ___________________ City: ______________ State: ____ Zip:____________

Family Physician:_________________________________ Office Phone: (

) _____________

Insurance Company: _____________________________ Policy # / ID #: ________________

Parent/Guardian:__________________Wk Phone: ( )________ Cell Phone: ( )__________

(minor participants only)

In an emergency, please notify:

Check here if same as above.

Name: ___________________________

Relationship: _________________

Work Phone: ( ) ________ Home Phone: ( ) __________ Cell Phone: ( ) ___________

Home Address: ________________________________________

City: ______________ State: _______________ Zip Code: ______________

Health History

1. Check all allergies participant my have and briefly describe the reaction:

Insect stings/bites ______________________

Seafood _________________

Asthma (allergy induced) ________________

Food (wheat/nuts) _________

Hay Fever ____________________________

Penicillin ________________

Other _________________________________________________________________

Check below if participant currently has or has had any of the following:

CONDITION

Past

Currently Has

Heart Defect/Disease

Diabetes

Hypertension

Epilepsy

Bleeding/Clotting Disorders

Asthma

Other:________________

Field Trip Health Form