Unaccompanied Minor Health Release Form

Student Name(Required)
Gender
Birth Date
Address

Parent/Guardian info

Name
Name
Address

Emergency Contacts

If unable to reach parents at above phone number(s), please contact:
Name
Name

Indicate any special health considerations of which our program staff should be aware. These include allergies or other conditions which might need attention at the conference. List any medication to be taken while at the conference. If more space is needed, please continue on the back.

Insurance Information

Please attach a copy of your medical insurance card with this form.
Address
Name of Insurance Holder

Medical Release

Reasonable effort will be made to reach you in the event of an accident or illness involving your child who requires medical attention. If you cannot be reached, your signature on the following release will ensure prompt care.
Consent(Required)
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.