The following medical infomration is needed in the event of an accident. Please complete this form as accurately as possibel. This form will only be used to help the Red Wing Environmental Learning Center staff respond to an emergency.

Name

First Name

Last Name

Email Address

Primary Phone

(###)

###

####

Graduating Class Year

Birthdate

YYYY

Male or Female

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent or Guardian (1)

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Parent or Guardian (2)

Parent or Guardian address if different

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent or Guardian (2) home phone

(###)

###

####

Parent or Guardian (2) cell phone

(###)

###

####

Parent or Guardian (2) email (optional)

Is the participant covered by family medical/hospital insurance?

INSURANCE CARRIER OR PLAN NAME

Group Number

Insurance Phone Number

(###)

###

####

Policy holder or insurance ID number

Primary Doctor

Primary Dentist

Any chronic medical condition/illness?

Please describe chronic medical condition/illness and management.

Any current medications (including over the counter or nonprescription drugs)?

Please list medications.

Any medication allergies?

Any food allergies?

Please describe allergic reaction and management.

Any other allergies? Please describe.

Immunization record up to date with school?

HAS/DOES THE PARTICIPANT (PLEASE EXPLAIN ANY YES ANSWERS BELOW):

Had any recent injury, illness or infectious disease?

Have a chronic or recurring illness/condition?

Ever been hospitalized?

Ever had any operations?

Had frequent headaches?

Ever had a head injury?

Ever been unconscious?

Ever passed out during exercise?

Ever had high blood pressure?

Ever had seizures?

Ever been diagnosed with a heart murmur?

Ever had any skin problems?

Have diabetes?

Have asthma?

Have hearing problems?

Wear contacts or glasses?

Ever had sprains or fracture?

Ever had frost bite?

Know how to swim?

Swim level

Any other medical contition(s) or informatin concerning the participant's behavior, physical or emotional condition that ELC should be aware of:

Parent/Guardian: The information contained on this form is accurate and complete to the best of my knowledge. I give the participant below permission to engage in all ELC activities. I give permission to ELC to provide routine hearlth care, administer prescribed medications and seek emergency medical treatment including x-rays or testes. I agree to tthe release of any records necessary for insurance purposes. I giver permission to the ELC to arrange any transportation necessary related to my child. In the even I cannot be reached in an emergency, I hereby give permission to the physician selected by ELC to secure and administer treatment, including hospitalization for the person named below. Type or digitally sign below.

Participant Name:

Parent/ Guardian Signature:

Red Wing Environmental Learning Center

Red Wing Environmental Learning Center

Student Information/Medical Form

Red Wing Environmental Learning Center

Red Wing Environmental Learning Center

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