Osher Lifelong Learning Institute at the University of Michigan

FIELD TRIP HEALTH INFORMATION FORM (CONFIDENTIAL)

Please fill out the form below and bring it with you on the day you will be participating in the field trip. Please turn this in to facilitator.

Name Date

Note: The facts you disclose will only be used to help staff prevent or respond to an injury during the trip.

Birthdate / /

Home Address

_

Home Phone( _ ) Cell Phone( _ ) ______

In case of emergency, please contact:

Name Relationship

Address

Home Phone( _ ) Work or Cell Phone( _ )

Doctor’s Name Doctor’s Phone( _ )

Medical Insurance Company

Policy Number ______

Please list and describe all information regarding the following:

Allergies

Disabilities

Heart Conditions

Current Medications

Are you allergic to bee stings? Y N If yes, do you carry medicine? Y N

Please check the following if appropriate and provide more information on the back, if necessary:

Asthma Convulsions Back Pain Epilepsy

Diabetes Heart Disease Fractures Other

Participant Signature:_______________________________________________