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Summer Intern Family and Emergency Information

The following information should be submitted online prior to arrival.  An original signed and notarized version, found in the Summer Intern Packet, must also be turned in at time of arrival. 

Intern's Name:   

Mother’s Information
Name:  
Home Phone   Work :       Cell:  
Email

Father's Information
Name:
Home Phone  Work :  Cell:
Email: 

In Case of Emergency Contact:  
                   Relationship to You:
                   Telephone Number:
Alternative Telephone Number:

MEDICAL AND INSURANCE INFORMATION

Family Insurance Company  
                     Policy Number

Family Physician  
                  Phone

Check applicable box and give appropriate information below:

None        Allergies         Asthma        Bronchitis         Diabetes         Dizziness
Heart Trouble         Kidney Trouble        Sinusitis        Stomach Upset    Other
Please explain any health issues:



Immunizations:
Tetanus.    Date Received:

Typhoid.    Date Received:


List below any prescription drugs the student will be taking while on trip. State frequency and dosage for each.

None



Are their any drugs or medicines that your child is allergic to? If yes, please specify.


EMERGENCY NOTIFICATION

Name:
Relationship:

Phone #: Alternative Phone #: