2025 Summer #2 Break Adult Team Lead Medical & Dietary Needs Form
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 (2/15/2025 - 2/22/2025)
Spring Break Trip (4/19/25- 4/26/2025)
Summer Break #1 (6/14/2025 - 6/21/2025)
Summer Break #2 (6/21/2025 - 6/28/2025)
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.