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:MaleFemaleParent/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:Date of last Tetanus Shot: Month Day Year Recommended every 10 years.Does your child wear glasses?YesNoDoes your child wear contact lenses?YesNoDoes 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): Asthma Fainting Headaches Fainting Toothaches Earaches Cramps Re-current bone, joint/muscle injuries Sleepwalking/talking Susceptibility to cold If yes to any of the above, please explain:Does your child take any medications?*YesNoPlease explain when and how they are to be taken:*Are there any behavioral/mental health problems that we should know about?*YesNoIf 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 This iframe contains the logic required to handle Ajax powered Gravity Forms.