MEDICATIONS Describe in detail any medications prescribed that will be used during the program:
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________ Can the student monitor and self-administer all medications without assistance? YES___ NO__
ALLERGIES Describe in detail any allergies and related treatments which will be used during the program: Allergy:____________________________ Reaction:_________________________________ Life Threatening?____________________ Medication:________________________________ Allergy:____________________________ Reaction:_________________________________ Life Threatening?____________________ Medication:________________________________ For allergic emergencies, will the student carry auto-injectable epinephrine (Epi-Pen) which he/she is able to self-administer? _________________________________________________ DIETARY RESTRICTIONS ______________________________________________________________________________ ______________________________________________________________________________ Please understand that we cannot control the contents of food products during travel. Should you have dietary allergies, you are ultimately responsible for inspecting all foods for ingredients related to the allergy. When traveling to Asia, please know that many foods are cooked in peanut oils. Based on the above information the student is cleared to travel: YES____ NO_____ Physician’s Signature: ________________________________________
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