Student Tour Client Form - Student Group Tours


Client Information Form
Name of Tour
Medical Information
First Name
Last Name
Health Insurance Number (OHIP or other)
Person to be notified in case of an emergency
Relationship to you
Full Address of person to be notified
Business Phone of person to be notified
Home Phone of person to be notified
Do you suffer from any of the following	Epilepsy Asthma Diabetes
Are you under any treatment which should be continued on the tour?	Yes No
If you answered yes, please specify
Do you have any allergies to any food or medications? Please specify
Do you have any food restrictions (religious or otherwise)? Please specify
Doctor's name
Doctor's address
Doctor's phone
Please read the following statement and sign and date the form, signifying your agreement with the contents of this form and with the statement below.
I am in good physical condition and able to participate in all regular activities. To the best of my knowledge the above information is correct. However, should it become necessary, I hereby give permission to the physician selected by the Group Leader, to hospitalize, or secure proper treatment for me in the case of an emergency.
Signature
Date