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Emergency Medical Form

Student Name*

Birthday*

Month

Day

Year

Gender*

Female

Male

Prefer Not To Say

Address*

Parent/Guardian Name

Full name*

Relationship to Camper*

Primary Phone*

Work Phone

Email*

Emergency Contacts (other than parent/guardian)

Name*

Relationship*

Phone*

Name*

Relationship*

Phone*

Medical Insurance

Insurance Provider*

Policy/Group Number*

Name of Insured*

Physician Information

Physician Name*

Physician Phone

Medical Information

Allergies (food, medication, environmental)*

None

Yes

If yes to please specify

Medical Conditions (asthma, diabetes, seizures, etc.)*

None

Yes

If yes to please specify

Dietary Restrictions*

None

Yes

If yes to please specify

Immunizations up to date?*

Yes

No

If yes to please specify

Physical, emotional, or behavioral conditions the camp should be aware of*

None

Yes

If yes to please specify

Activities from which camper should be exempted for health reasons*

None

Yes

If yes please specify

Medications (include dosage, frequency, and reason*

None

Yes

If yes please specify

Activities from which camper should be exempted for health reason*

None

Yes

If yes please specify

Authorization for Emergency Medical Care

In the event of an emergency, I authorize the staff of Tech Time Cincinnati Foundation’s NextGen AI Summer Programs to obtain medical care for my child as deemed necessary, including transportation by ambulance if required. I understand that every effort will be made to contact me or the emergency contacts listed above. I accept responsibility for all medical expenses incurred.

Name*

Date*

Month

Day

Year

Signature*

Sign in the box or use the keyboard to type.

Signature field is empty.

All information provided will be kept confidential and used solely for the safety and well-being of your child during camp.