Youth Medical Information Form | Naturally Superior Adventures

Confidential. For staff/administration use only!

Child's Name:*

First Last

Trip/Program Name:*

Trip/Program Dates:*

Your Childs Birthdate:*

Month

Day

Year

Gender:

Male
Female

Parent/Guardian Contact Info

Parent Email:*

Best number to contact you at:

Best time to contact you:

Anytime is great!
Morning (between 9:00-11am EST)
Afternoon (between 1-5pm EST)
Evening (after 6pm EST)

Parent or Guardian's Name #1:*

First Last

Parent or Guardian's Name #2:*

First Last

Parent/Guardian #1 Phone Number (home):

Parent/Guardian #1 Phone Number (work):

Parent/Guardian #2 Phone Number (home):

Parent/Guardian #2 Phone Number (work):

Emergency Contact Info

Emergency Contact Name:*

First Last

Relationship:*

Emergency Contact Phone:

Other ways to contact this person:

Health Provider Info

Health Care Provider:

Policy Number:

Doctor's Name:

Doctor's Phone Number:

Date of last Tetanus Shot:

Month

Day

Year

Recommended every 10 years.

Does your child wear glasses?

Yes
No

Does your child wear contact lenses?

Yes
No

Does your child have any allergies that our staff should be aware of? (Check any that apply.)

Penicliin
Aspirin
Tylenol
Plants
Insect Bites
Bee Stings
Any other drugs

Does your child have any food allergies/intolerances? Please describe:

Please indicate if your child has any of the following conditions (check any that apply):

If yes to any of the above, please explain:

Does your child take any medications?*

Yes
No

Please explain when and how they are to be taken:*

Are there any behavioral/mental health problems that we should know about?*

Yes
No

If yes, please explain what they are and how we can best deal with them:*

Is there anything else you would like us to know about your child?

I agree that the information I have provided is correct and complete to the best of my knowledge.*

I agree

Youth (under 18) Medical Information Form

Youth (under 18) Medical Information Form

Parent/Guardian Contact Info

Emergency Contact Info

Health Provider Info