Shirts Across America · 2017-18 Airline & Medical Form

Participant Information

Full/Formal Name (as appears on ID)

*

First Name

Last Name

Email

*

Email where you would like to receive confirmation of submission.

Verify Email

*

Gender

*

Birthdate (Example: MM/DD/YYYY

*

Please double check this... Very important.

School you attend or are affiliated with:

*

Which trip are you traveling to New Orleans with SAA?

*

Medical Information

Insurance Provider

*

Policy Number

*

Primary Doctor's Name

*

Primary Doctor's Phone Number

*

Do you have asthma, respiratory condition(s) or allergies to mold?

*

Do you have a history of reactions to heat?

*

Are you diabetic?

*

Do you have a history of seizures?

*

Dietary Restrictions

*

We will pass all dietary restrictions/information to the kitchen staff at our partnering accommodations, but not all dietary restrictions are able to be accommodated. Individuals with less common or multiple dietary restrictions should plan to pack or buy supplemental food while in New Orleans.

No Dietary Restrictions

Dairy Free

Gluten Free

Peanut Allergy

Pescatarian (no animal products, but will eat fish)

Vegan (no animal products)

Vegetarian (no animal meat)

Other (please elaborate below)

Further information about allergies, medication and particular health concerns:

*

Emergency Contact

Primary Emergency Contact Name

*

First Name

Last Name

Primary Emergency Contact Phone

*

Will your parent(s)/guardian(s) be traveling while you are in New Orleans?

*

Secondary Emergency Contact Name

*

First Name

Last Name

Secondary Emergency Contact Phone

*

If they will be traveling, please provide any helpful details here:

Helpful information includes location of travel, additional contact information if destination is abroad, etc.

Medical Insurance Card

Please upload a copy/photo of the FRONT of your Medical Insurance Card

*

Please upload a copy/photo of the BACK of your Medical Insurance Card

*

Airline & Medical Information

Participant Information

Medical Information

Emergency Contact

Medical Insurance Card