Travel Abroad Medical Release Form
Participant Information
Full Name
Date of Birth
Passport Number
Home Address
Phone Number
Email
Emergency Contact
Name
Relationship
Phone Number
Medical Information
Primary Physician
Physician Phone Number
Allergies
Current Medications
Medical Conditions
Medical Release Authorization
I hereby authorize any licensed healthcare provider to provide any necessary medical treatment while traveling abroad. I further authorize release of medical information to necessary personnel.
Signature
Date