EmailMeForm
Authorization for Emergencies
A representative from Genesis will notify you if your child is ill, injured, or misbehaving. If you cannot be reached, your child will be taken to the nearest emergency hospital or facility providing medical or dental services.
If your child is seriously misbehaving, he/she will be taken to the nearest airport and sent home at your expense.
Parent/Guardian Agreement
I,
"parent/guardian"
of hereby authorize Genesis HBCU Tours and its representatives to seek and authorize all emergency medical services and behavioral interventions needed for my child. This authorization is effective from our departure on October 16th through our return on October 21st.
Parent/Guardian’s Name
*
First
Last
Medical History Information
Information requested below is mandatory and confidential and will only be shared with appropriate representatives of Genesis.
My child is taking medication(s).
*
Yes
No
My child is taking the following medications in the dosages noted:
Dosage information....
My child has been diagnosed with the following medical conditions:
List any medical conditions...
My child is allergic to peanut products
Yes
No
My child is allergic to shellfish
Yes
No
My child is allergic to
Yes
No
Medical Insurance Carrier:
Medical Insurance Group Number:
Address:
Physician Name:
Physician Name:
Phone:
###
-
###
-
####
Parent/Guardian Signature
*
Clear
Use mouse or touch-pad
Date Time
*
MM
/
DD
/
YYYY
