Group Trip Medical Consent Form

Participant Information

Full Name

Date of Birth

Phone Number

Address

Medical Information

Allergies Current Medications Existing Medical Conditions Health Insurance Provider Policy Number

Emergency Contacts

Emergency Contact Name Relationship Contact Phone

Medical Consent & Authorization

I hereby authorize the trip organizers and their representatives to obtain necessary medical treatment in the event of an emergency. I understand that every effort will be made to contact the emergency contact listed above.

Signature

Date