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The Honors Experience Medical Form

Student Information

First Name

Last Name

Birthdate

Birthdate

Email Address

Mailing Address

Mailing Address

Country

Street

City

Region

Postal Code

Emergency Contact Information

First Name

Last Name

Relationship to you

Mobile Number

Work Number

Address

Address

Country

Street

City

Region

Postal Code

Medical/Insurance Information

Medical Insurance Carrier Name

Policy Number

The following information will be used to assist on-site personnel if you have a health emergency:

List prescription medicines and dosages you are taking:

List any allergies you have:

Other health information we need to know:

Immunizations

Tetanus and diphtheria

Measles, mumps, rubella

I hereby certify that I am in good health and that there should be no problems regarding my condition that might prevent me from participation in all scheduled activities (sign by typing your name in the box below)

Parent/Guardian Signature (sign by having your parent/guardian type his/her name in the box below)