Apple Tours & Travel, Inc

Apple Tours & Travel, Inc. Health Information

Must be completed by all tour participants. Please PRINT legibly.

Name of Tour Participant ______School ______

Person to call in case of emergency:

1) ______relationship to student ______Home phone ______Work phone ______Cell phone ______2) ______relationship to student ______Home phone ______Work phone ______Cell phone ______3) ______relationship to student ______Home phone ______Work phone ______Cell phone ______

* Are there any health problems that may affect your child during the tour? If so, please specify: ______

* Does your child have any medication in their possession? ____ yes ____ no If yes, please list and explain for what purpose the medication was prescribed. ______

* List any allergies to medication: ______

*Does the chaperone in charge have your permission to administer over-the counter medications for minor ailments such as headaches, upset stomach, rashes, or cuts for your child? ____ yes ____ no

Name of Insurance Company ______Policy Number ______ID # ______If this insurance is provided through a parent or guardian’s employer, please give the company name and address of the employer: ______

Medical Treatment Release: I give my permission as parent/guardian of the above listed minor to procure emergency medical care for my child due to accident or illness in the event that in the opinion of the teacher or other tour chaperone if it becomes necessary. Such care may be procured without further consent of either of us. I agree to be solely responsible for the payment of any bills accrued in the process of aiding my child, not covered by insurance.

______Printed name of parent/guardian Signature of parent/guardian Date