North Carolina Geology Field Course

Student Health Form

 

Information on this form is strictly confidential and will only be used in case of an emergency.  This form will be destroyed at the end of the 2018 North Carolina Geology Field Course.

 

Please print or type

 

Student Information

 

______________________           _______________________           ______________________

Last Name                              First Name                                           Middle Name

 

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Street Address

 

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City or Town                                      State                                                            Zip Code

 

           

            Emergency Contact Information

 

            _____________________________________                      ______________________________

            Name                                                                          Relationship

 

            ____________________________________________________________________________

            Address – Street, City, State, and Zip Code

 

            ____________________              ____________________              _____________________

            Home Phone                          Work Phone                           Mobile Phone

           

 

            Health Insurance Information

 

            _____________________________________________________________________________

            Company or Organization

 

            _____________________________________________________________________________

            Address – Street, City, State and Zip Code                       Phone Number

 

            _____________________________________________________________________________

            Policy or Contract Number                                                  Expiration Date

 

 

            Physician(s)

 

            _____________________________________________________________________________

            Name

            ______________________________________________________________________________

            Address – Street, City, State, and Zip Code                      Phone Number

 

 

Medical Information

 

Do you have a Medic alert tag/bracelet?  If “yes”, for what condition?

 

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Allergies (food, insects, medications, other)

 

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Do you carry medications for your allergies?  If “yes”, list medications and dosages.

 

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Current medications (Include herbal and over the counter medications as well as prescription medications)

 

_____________________________________________________________________________________________

 

_____________________________________________________________________________________________ 

 

 

Pertinent Medical History

(Please list medical conditions, e.g., diabetes, asthma, seizures, high blood pressure, etc. or any physical conditions that might be important for emergency care.)

 

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_____________________________________________________________________________________________

 

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Immunizations with Dates Relevant to the Field Trip or Program (e.g., Tetanus)

 

____________________________________________________________________________________________

 

____________________________________________________________________________________________

 

 

Special Beliefs

(Any religious or other beliefs that might have an impact on medical care)

 

_____________________________________________________________________________________________

 

Important Notice: 

This form contains medical information that accurately reflects

Known medical conditions and medications I am currently taking.

 

___________________________________________                        ___________________________

Student’s Name                                                                     Date

 

___________________________________________                        North Carolina Geology Field Course 2018

Student’s Signature