2024-25 Medical & Dietary Needs - October Adult Immersion Trips

Participant Name

First Name

Last Name

Preferred Name

Emergency Contact Name

First Name

Last Name

Cell Phone

Best phone number to reach Emergency Contact

Email

Trip Dates

Diagnosed Allergies

Have you been diagnosed with allergies by a healthcare professional? If so, list any diagnosed allergies

Allergies - Other

Is there any general allergy information about you SAA should know about?

Epi-Pen

Do you carry an epinephrine auto-injector (Epi-Pen)?

Life Threatening Allergies

Do you have a life threatening allergy to food, etc?

Health/Medical Dietary Issues

Do you have a special diet or have to avoid certain foods?

List any prescribed medications you will be traveling with that SAA should know about:

Please indicate N/A if none.