Toucan Abroad Medical Form

This information is treated with the greatest possible confidentiality. Full disclosure is important for proper care in case of an emergency. To help ensure a participant's safe participation, we may ask that a participant have a physician's examination or provide additional documentation to verify the participant's physical and/or emotional ability to participate in the Program. Failure to provide full, accurate and up-to-date health information may be grounds for a forfeiture of one's space in the program.

Name *
Name
Basic Medical Information
If you do not have any medical conditions please write N/A.
If you do not take any prescription medication please write N/A.
If no, please write N/.A
If you do not have allergies please write N/A.
Dietary Restrictions
If you do not have dietary restrictions, please write N/A.
Asthma Questionnaire
You must bring an inhaler if you have had asthma in the last 5 years.
Medication Policy
Please check the space below to confirm you will be responsible for bringing the following over-the-counter medications and are capable of taking them. If you have an allergy to any medication listed below and will not be bringing it, please specify the medication and reasons in the space below. *
*Over-the-Counter Medications: Pain or fever reducer (e.g. aspirin, acetaminophen, ibuprofen) Insect Repellent Topical anti-itch creams (e.g. cortisone cream, antihistamine cream for mosquito bites) Topical antibacterial cream (to prevent infection on cuts/insect bites) Cold/cough meds Allergy meds Digestive meds (e.g. nausea, diarrhea, antacids) Motion Sickness meds such as dramamine Sunscreen Other
If you are not bringing additonal medications, please write N/A/
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone