Health Form

In the event of a medical emergency, I give Sara Sills and/or Stephanie Heitz the authority
to seek medical attention for my child. If, in the event I cannot be reached, I further give
these individuals the authority to make emergency medical decisions regarding my child
while on tour in June 2015 through England and France.
Additional/ Special Health or Medical Instructions
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Health Information
Please list below any known allergies, illnesses, or other medical information applicable to
your child:
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Please list below any medication your child is allowed to take and/or purchase on tour
including varieties of aspirin, Tylenol, Dramamine, or other over-the-counter or prescription
drugs. Please indicate with a ** which drugs are prescription and will be with your child
before the tour begins in their original medical containers.
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By signing this form, I acknowledge that the information given above is accurate and
complete to the best of my knowledge. I also acknowledge that, in the event my child has
to seek emergency medical assistance, other medications may be prescribed and
consumed. Note: Names and signatures of both parents are required only if both parents
are legal guardians and have full or partial custody of the child.

Students Full Name (please print): ________________________________________________________

Fathers Full Name (please print): _________________________________________________________
Mothers Full Name (please print): ________________________________________________________
Fathers Signature: _______________________________________________ Date ________________
Students Signature: ______________________________________________ Date ________________
Mothers Signature: _______________________________________________ Date ________________