Medical Information – Youth Programming Youth Programming – Medical and Emergency Information Form This field is hidden when viewing the formNext Steps: Install the User Registration Add-OnThis form requires the Gravity Forms User Registration Add-On. Important: Delete this tip before you publish the form.Full Name of Participant(Required) First Last Pronouns Date of Birth(Required) MM slash DD slash YYYY Primary Contact (Parent/Guardian)(Required) First Last Relationship to Participant Phone Number Email(Required) Emergency Contact (other than primary contact)(Required) First Last Relationship to Participant Phone Number Does the participant have any allergies (food, insect, medication, environmental, etc.)?(Required) Yes No If yes, please list and describe reaction/severity:Does the participant carry an EpiPen or other emergency medication?(Required) Yes No If yes, please explain:Does the participant have any chronic medical conditions (e.g., asthma, diabetes, seizures, heart conditions)?(Required) Yes No If yes, please describe:Does the participant have any physical, behavioral, or emotional considerations that we should be aware of to support their experience at camp?(Required) Yes No If yes, please describe:Please use this space to expand on the topics above or add additional relevant informationPermission(Required) I authorize Kalamazoo College Outdoor Leadership Training Center staff to provide basic first aid to my child if needed.(Required) In the event of a medical emergency, I authorize emergency medical personnel to treat and transport my child.(Required) I will inform the program of any medical condition changes prior to camp.Signature(Required) By signing my name, I acknowledge that this electronic signature is valid and binding, and I certify that the information provided is accurate to the best of my knowledge.Name First Last Date MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. Δ
