2023 Medical & Dietary Needs Form - Adult Immersion Trips
Participant
Name
First Name
Last Name
Preferred Name
Emergency Contact Name
First Name
Last Name
Cell Phone
Best phone number to reach Parent/Guardian.
Email
Trip Dates
Please select...
Civil Rights Immersion Trip (3/1/2023 - 3/5/2023)
Civil Rights Immersion Trip (4/19/2023 - 4/23/2023)
Human Rights Immersion Trip (5/17/23 - 5/21/23)
Diagnosed Allergies
Please select...
Yes
No
Have you 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 you SAA should know about?
Epi-Pen
Please select...
Yes
No
Do you carry an epinephrine auto-injector (Epi-Pen)?
Life Threatening Allergies
Please select...
Yes
No
Do you have a life threatening allergy to food, etc?
Health/Medical Dietary Issues
Please select...
Yes
No
Do you 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.