2026 MWB 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

Diagnosed Allergies

Have you ever been diagnosed with allergies by a healthcare professional? If so, list any diagnosed allergies

Allergies - Other

Is there any general allergy information about you SAA should know about?

Epi-Pen

Do you carry an epinephrine auto-injector (Epi-Pen)?

Life Threatening Allergies

Do you have a life threatening allergy to food, etc?

Health/Medical Dietary Issues

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.