2024 Adult Team Lead Medical & Dietary Needs Form -SB
Adult Team Lead
Name
First Name
Last Name
Preferred Name
Adult Team Lead
Cell Phone
Adult Team Lead
Email
Trip Dates
Please select...
Mid-Winter Break Trip (2/17/2024 - 2/24/2024)
Spring Break Trip (3/30/2024 - 4/6/2024)
Summer Break #1 (6/8/2024 - 6/15/2024)
Summer + Trip (6/15/2024 - 6/22/2024)
Summer Break #2 (6/22/2024 - 6/29/2024)
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.