Name

Health Form & Release

Required for ALL students traveling with the tour group

(Parents/Guardians/Other Travelers May submit the form if you would like the medical personnel on tour to have access to this information.)

*Submit your form NO LATER THAN March 1, 2022

Name

Email

Age on July 10, 2022

Date of Birth

Street Address

City

State

Zip Code

Health Insurance Provider

Policy #

Group #

Please provide a family emergency contact:

Contact Name

Contact Email

Contact home phone

Contact mobile phone

Please provide a nonfamily emergency contact:

Alternate Contact Name

Alternate Contact Email

Alternate Contact home phone

Alternate Contact mobile phone

Medical Conditions: Check All that apply

Add explanation(s) in the box below

Heart Condition

Respiratory Condition

Diabetes

Special Dietary Needs

Please provide explanation(s) for any of the conditions checked above:

Current Medication(s) (list dosage and frequency):

Allergies: Please list and include treatment required:

OTC Medications Permitted (check all that apply):

Tylenol

Ibuprofen

Aleve

Benedryl

Imodium

In case of an accident or serious illness, I understand that YOBC will contact me. If YOBC is unable to reach me, the administrator in charge has my permission to obtain the services of a physician and/or hospital until I can be reached.

I, the undersigned member and/or member's parent or guardian, hereby indemnify and hold harmless YOBC, its officers, directors, tour chaperones, and all other agents against and from any and all claims, damages, injuries, demands, expenses, or losses, direct or indirect, arising out of or related to the rendering or failure to render medical treatment.

 

Student forms require the signature of the student AND parent/guardian.  If you are submitting a form for a parent/guardian, only one signature is required.

YOBC Member Name

Parent/Guardian Name

Today's Date