Unaccompanied Minor Health Release Form

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Attendee Type

Unaccompanied Minor

Parent

Name(Required)

First Last

Gender

Female

Male

Birth Date

Age

Grade this Fall

Address

Street Address Address Line 2 City State ZIP Code

Host family at conference

Program at conference

Parent/Guardian info

Name

First Last

Phone

Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Emergency Contacts

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

Name

First Last

Relationship

Phone

Name

First Last

Relationship

Phone

Health Information

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.

Medical Insurance Provider

Address

Street Address Address Line 2 City State ZIP Code

Policy/Group/Account #:

Member ID #

Name of Insurance Holder

First Last

Relationship to student:

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.

Signature(Required)

Today's Date

This field is for validation purposes and should be left unchanged.

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Personal Reference Form

Unaccompanied Minor Health Release Form

Unaccompanied Minor Health Release Form

Parent/Guardian info

Emergency Contacts

Insurance Information

Medical Release