Emergency Contact Emergency Form Trip Participant name * Name of parent or caregiver Parent or caregiver phone Medical Information This information is held in strict confidentiality and is destroyed following the trip. *IMPORTANT* In the event that there is an emergency or accident, I agree to have my child transported to the nearest emergency center or hospital. I hereby authorize the physician and/or hospital to give whatever emergency treatment may be necessary to my child. List any medications you will be sending which you permit your child to use. Please note whether the medication is for daily use or as needed. It is NOT necessary to list over-the-counter medications. List any known medical conditions that could be helpful in emergency situations. Emergency Contact In the event that we cannot contact a parent in an emergency, we need information about another adult that we have your permission to contact. Please provide the required information. Name of emergency contact Address Phone Cell phone Submit If you are human, leave this field blank. Δ