Field Trip Participant Medical Information and
Emergency Contact Information
Field Trip Title: _______________________________________________
Dates of CSPG Field Trip: _______________________________________________________
Location of CACMC Field Trip: ___________________________________________________
Participant’s Name: ___________________ Birthdate (da/mo/yr):________/_____/________
Name of Family Physician: _______________________Phone No: _____________________
Health Care Carrier & No: _________________________ & ___________________________
Medical conditions/information (allergies, medications, religious exclusions, etc.) that should be communicated to a doctor in the event of an emergency:
Please list any prescription drugs and frequency that you are currently taking:
Please list any food allergies:
Participants are responsible for the administration of their own drugs. There will be no registered
medical professionals on CACMC field trips.
1st Emergency Contact: ___________________________________________________
Relationship: ___________________________________________________________
1st Emergency Contact Information:
Home Phone________________ Work Phone________________ Cell Phone _____________
1st Emergency Contact Address: ___________________________________________
2nd Emergency Contact: __________________________________________________
Relationship: ___________________________________________________________
2nd Emergency Contact Information:
Home Phone________________ Work Phone________________ Cell Phone _____________
2nd Emergency Contact Address: __________________________________________
Do you have a valid Standard First Aid and CPR Certificate? □ YES □ NO
If YES, would you be willing to be a First Aider? □ YES □ NO
If NO, are you prepared to take a Standard First Aid and CPR course paid for by the CACMC?
□ YES □ NO
Are you willing to be a driver? □ YES □ NO
