Emergency Medical Release Form
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1Emergency Medical Release
THIS FORM SHOULD BE COMPLETED AND RETURNED TO YOUR TEACHER
Participant’s Name ______________________________________
Birthdate ______________________________
Street Address ___________________________ City _____________________ State ________ Zip _____________
EMERGENCY INFORMATION
Father's Name _______________________ Home Phone (
)
Bus Phone (
)___________
Cell Phone (
)_______________
Mother’s Name ______________________ Home Phone (
)
Bus Phone (
)___________
Cell Phone (
)_______________
In an emergency when parent/guardian cannot be reached, please contact the following:
Name _____________________________
Home Phone (____)____________
Bus Phone (_____)____________
Name _____________________________ Home Phone (____)_____________
Bus Phone (_____)____________
Allergies _____________________________________________
Last Tetanus __________________ ____________
Other medical conditions ____________________________________________________________________________
________________________________________________________________________________________________
Medication being used (include dosage/frequency) _______________________________________________________
________________________________________________________________________________________________
Present state of health ______________________________________________________________________________
Family Physician _____________________________________________ Phone (____)________________________
Medical/Hospital Insurance Company _____________________________ Phone (____ )_______________________
Policy Holder’s Name ______________________________________ Policy Number ___________________________
AUTHORIZATION FOR TREATMENT OF MINOR
I, the undersigned, understand and acknowledge that every effort will be made to contact the parents in case of
an emergency, and, if possible, before any medical treatment is administered. In the event of an emergency or if the
parents cannot be notified, I hereby give permission to the Program Leader or the WorldStrides staff to secure proper
treatment for my child. If necessary, this includes selection of physicians and medical treatment facility who are then
authorized to perform such medical treatments as deemed necessary to protect the health of my child.
In the event of any emergencies during the trip, the undersigned hereby grants authority to be exercised at the
discretion of the Program Leader or chaperone to dispense over-the-counter medication.
Date
Signature of Parent/Guardian
Please return this form to
no later than ~ .
PLEASE DO NOT RETURN THIS FORM TO WORLDSTRIDES.
OVER
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