Youth (under 18) Medical Information Form 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 InfoParent 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 InfoEmergency Contact Name:* First Last Relationship:* Emergency Contact Phone:Other ways to contact this person:Health Provider InfoHealth Care Provider: Policy Number: Doctor's Name: Doctor's Phone Number:Please rate your general health1=weak & 5=excellent 1 2 3 4 5 Please rate your level of fitness1=weak & 5=excellent 1 2 3 4 5 Please rate your swimming ability1=weak & 5=excellent 1 2 3 4 5 Health Conditions – Please describe any health conditions that may affect your child’s participation.Allergies: - Please detail any allergies, reactions and treatmentMedications – Please detail all medications, when and how they are taken. Allergies: - Please detail any allergies, reactions and treatmentDietary – Detail any dietary restrictions and preferencesBehavioral – Detail any behavioral/mental health problems how we can best deal with them.I agree that the information I have provided is correct and complete to the best of my knowledge.* I agree