2022 Medical & Dietary Form
Student
Name
First Name
Last Name
Preferred Name
Parent/Guardian Name
Parent/Guardian First Name
Parent/Guardian
Last Name
Parent/Guardian Cell Phone
Best phone number to reach Parent/Guardian.
Parent/Guardian Email
Trip Dates
Please select...
Spring Break (4/16/2022 - 4/23/2022)
Summer Break #1 (6/11/2022 - 6/18/2022)
Summer Break #2 (6/25/2022 - 7/2/2022)
Diagnosed Allergies
Please select...
Yes
No
Has the student ever been diagnosed with allergies by a healthcare professional? If so, list any diagnosed allergies
Allergies - Other
Please select...
Yes
No
Is there any general allergy information about the student SAA should know about?
Epi-Pen
Please select...
Yes
No
Does the student carry an epinephrine auto-injector (Epi-Pen)?
Life Threatening Allergies
Please select...
Yes
No
Does the student have a life threatening allergy to food, etc?
Health/Medical Dietary Issues
Please select...
Yes
No
Does the student have a special diet or have to avoid certain foods?
List any prescribed medications you will be traveling with that SAA should know about:
Please indicate N/A if none.