Health Form

In order for us to take the best care of you and/or your child during your program, parents/guardians (for students under 18 years old), or travelers who are 18+ years old, are required to fill out this form.

This form will be shared only with The Global Citizen Program’s staff and your teacher-leaders.

Traveler's First Name

Traveler's Last Name

Date of Birth

YYYY

Parent / Guardian's Name

First Name

Last Name

Parent/Guardian Phone

(###)

###

####

Second Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Primary Care Physician's Name

First Name

Last Name

Primary Care Physician's Phone

(###)

###

####

Acute Medical Issue?

Vision Impairment

Hearing Impairment

Physical Impairment

Seizures or Epilepsy

Diabetes Type I / Type II

Psychological Conditions

Depression, Anxiety, Eating Disorders, etc.

Behavioral Conditions

ADHD, Autism, etc.

If you answered, YES, to any of the above, please explain and share any relevant info for the teacher-leaders.

Please list any prescribed medications and reason for use. Students must carry and administer all their own medications and treatments.

Please share any additional medication, or other important information about your child's medications.

Allergies

Please share any known allergies and reactions.

Please share any other important information on allergies.

For allergic emergencies, does the student carry an auto-injectable epinephrine?

Dietary Requests

Vegetarian, vegan, gluten-free, etc

Please share any other information that will allow our teacher-leaders to best care for your child's physical, mental and emotional well-being.

We require all students to be able to care for their own recurring medical treatments without supervison. All medications, including injections and other treatments, must be monitored and administered by the student. Student's must remind the wait staff at all restaurants of any allergy.

Check if you have fully read, and shared all current health conditions.

Check if you would like one of your child's teacher-leaders to contact you to review any part of this health form.