CCAC Travel Information Form
Name ___________________________________________________ Age _______
Address _____________________________________________________________
_____________________________________________________________
Phone: Cell/Home ________________________ Work _______________________
Physician's Name _________________________ Phone _______________________
Health Insurance Carrier ________________________________________________
Policy Number ________________________________________________________
In case of an emergency, please contact:
1. Name ________________________________________ Phone _______________
2. Name ________________________________________ Phone _______________
Your Personal Medical History:
Please list any medications are you currently taking? __________________________
Please list any medications are you allergic to? _______________________________
Please list any significant medical conditions ________________________________
I authorize the release of this information whenever necessary by an authorized representative of the CCAC.
Participant's signature _______________________________________ Date _______
This form is to be carried by the trip supervisor at all times and is required to be completed by all (Employees and Students) traveling with CCAC.
This form will be kept confidential.
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