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 2019 North Carolina Geology Field Course.

Please print or type

Student Information

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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

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Name Relationship

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Address – Street, City, State, and Zip Code

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Home Phone Work Phone Mobile Phone

Health Insurance Information

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Company or Organization

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

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Policy or Contract Number Expiration Date

Physician(s)

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Name

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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)

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

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Special Beliefs

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

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Important Notice:

This form contains medical information that accurately reflects

Known medical conditions and medications I am currently taking.

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Student’s Name Date

___________________________________________ North Carolina Geology Field

Student’s Signature Course 2019