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Personal Information Name ______________________ Date of Birth - ________________ Address_ ____________________ ____________________________ Phone - _____________________ Cell _________________________ Emergency Contact Name _______________________ Relationship __________________ Phone _______________________ Alternate phone number ____________________________ Medical and Insurance Information Insurance Co: ___________________ Policy # ________________________ Family Physician:____________________________ Phone: ____________________________________ Permission I do hereby verify that the information below is correct and grant permission to : _____________________________________ to obtain medical attention in case of my sickness or injury. I hereby grant permission for an attending physician or hospital to perform whatever care deemed necessary for my welfare as consented by at least one of the above parties. Name ________________________________ Signature ___________________________ Date ________________________________ | Check applicable spaces and give appropriate information below: Allergies_________ Insects__________ Medicines________ Asthma__________ Bronchitis________ Diabetes_________ Dizziness________ Heart Trouble__________ Kidney Trouble__________ Sinusitis_________ Stomach Upset___________ Other ________________ Immunizations Tetanus: Date received ________________ List any prescription drugs the student will be taking while on trip; state frequency and dosage for each. _____________________ ___________________ |