Microsoft word - student health form.docx

Please read WIESCO’s conditions carefully before submitting your application. After completing the
application and the health form please send by February 15, 2014: both documents, a current picture
of yourself and the registration fee to:
2014 Registration Fees
15065 Shoreline Drive
Merrill, WI 54452

Studentʼs Name:
Emergency phone numbers
Alternate contact (preferably a relative):
Birthday (mm/dd/year):
Name of Studentʼs Parent(s):

Do we have permission to administer the following to your son/daughter if needed?

 Tylenol  Aspirin  Dramamine  Antacid
Do we have permission to take your son/daughter to a medical facility if needed?

Please indicate any medical problems or medication needs your son/daughter has that we should be
aware of:
Are there activities in which your son/daughter may not be able to participate?
 No
 Yes (please list):

My son/daughter has permission to (please check those that apply):
 Leave the camp to stay at the home of a family if invited and has the approval of the American director after reviewing the request  Swim in a pool, lake or sea  Be unsupervised in the host town during the day or evening  May stay behind at the lodging site during weekend excursions if not feeling well I understand that there are dangers involved in any trip and that the rules are for the safety of all travelers. I understand that my son/daughter may/may not consume alcohol and is not to be out of their room after curfew. I understand that my son/daughter must adhere to the rules set by the teachers-chaperons regarding the above items and any rules set for any situation that may arise. I further understand that there are times during the day and from after bed check until the next morning that the students are not chaperoned. I understand that the teacher-chaperons and WIESCO, INC. directors have my permission to make parental decisions regarding my son/daughter. In the event of a serious behavior problem, the chaperons and/or directors have my permission to send my son/daughter home at my expense. 
I, __________________________________ the parent/guardian of _______________________________, understand that there are conditions and risks that may cause injury. I agree that my son/daughter is responsible for his/her own safety while on the trip and travel agencies, WIESCO, INC., or its directors, and teacher-chaperons are not responsible for any injuries that may occur. We, parents/guardians and our son/daughter, specifically RELEASE, DISCHARGE, HOLD HARMLESS, in advance, all of the above-named persons from any and all liabilities that may arise from the trip.
 My son/daughter has and agrees to maintain throughout the entire trip, valid and sufficient medical insurance. I understand that this is my responsibility and release all persons identified above from providing such insurance coverage. I further understand that the foreign country medical facilities may not accept such insurance, that any medical services must be paid for in cash, and that I am responsible for reimbursing payment and submitting my own insurance claim.
 We agree that my son/daughter will accept and abide by all rules and policies imposed by WIESCO, INC. Directors or teacher-chaperons. This acknowledgement and assumption of risk and release shall be upon us, parents/guardians. We hereby consent to our son/daughterʼs participation in the program. Signature(s): __________________________________ __________________________________ Student Signature: ______________________________________ Signed: ______________________________________


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