Health/Accidental Insurance Information:
Health/Accident Insurance Company
The following immunizations are recommended. Tetanus immunization is required and must have been received within the last 10 years.
Bring enough medications in sufficient quantities and in the original containers. Make sure that they are NOT expired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication unless instructed to do so by your doctor.
ADULTS AUTHORIZED TO TAKE YOUTH TO AND FROM EVENTS:
You must designate at least one adult. Please include a telephone number.
I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity.
I give permission for full participation in Trail Life USA activities, except where specifically limited in writing herein.
ThisHealthandMedicalRecordiscorrectandcomplete,asfarasIknow. IherebygivepermissionforTrailLifeUSAleadershiptoadminister prescribed and noted over the counter medications.
Incaseofemergency,Iunderstandeveryeffortwillbemadetocontactme. IntheeventthatIcannotbereached,Iherebygivemypermissionto the licensed health-care provider selected by the Trail Life USA adult leader(s) to secure proper treatment, including related transportation, hospitalization, anesthesia, surgery, or injections of medication for my child, except as noted below. I agree to the release of records necessary for treatment.
AGREEMENT: By entering text in the below, "signature" field, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.
If we need to know anything else, please use this area for that.
Thank you for submitting your Health and Medical Information.