Minor Group Travel Medical Authorization Form
Minor's Information
Full Name
Date of Birth
Age
Address
Group/Organization Name
Parent/Guardian Information
Parent/Guardian Full Name
Phone Number
Email
Emergency Contact (Other than Parent/Guardian)
Full Name
Phone Number
Relationship to Minor
Medical Information
Primary Physician Name
Physician Phone
Insurance Provider
Policy/Group #
Known Allergies or Medical Conditions
Current Medications
Doctor's Permission/Restrictions
Authorization
Authorization Statement
Parent/Guardian Signature
Date