WIESCO, INC. STUDENT HEALTH FORM

Name_____________________________________Birthdate:________________
Address_____________________________ Student’s Parent_________________
Emergency phone numbers: Day______________ Night______________________
Alternate person (relative) to be contacted: ________________________________
Address _______________________________ Phone: _____________________

Do we have permission to administer the following to your son/daughter if needed? Please answer "yes" or "no".
Tylenol____/ Aspirin ____/ Dramamine____/ Anti-acid ___/ Other Medications? Please list:____________________________________________________________________
Do we have your permission to take your son/daughter to a Medical Facility if needed?_____
Please indicate any medical problems or medication needs your son/daughter has that we should be aware of_______________________________________________________________
______________________________________________________________________
Are there some activities in which your son/daughter may not be able to participate? Please list:____________________________________________________________________
My son/daughter has my permission to (please check those that apply): ____ leave the camp to stay at the home of a family, if invited, and has the approval of the American leader after reviewing the request; _____swim at a pool, lake or the sea; _____be unsupervised in the city during the day or the evening; _____may stay behind at the hotel during the tour if not feeling well. I understand that there are dangers involved in any trip and that the rules are for the safety of all travelers. I understand that my son/daughter may/may not consume alcohol and is not to be out of their room after curfew. I understand that my son/daughter must adhere to the rules set by the teachers-chaperons regarding the above items and any rules set for any situation that may arise. I further understand that there are times during the day and from after bed check until the next morning that the students are not chaperoned. I understand that the teacher-chaperons and WIESCO, INC. Directors have my permission to make parental decisions regarding my son/daughter. In the event of a serious behavior problem, the chaperons and/or Directors have my permission to send my son/daughter home at my expense.
I, ________________________the parent/guardian of ___________________, understand that there are conditions and risks which may cause injury. I agree that my son/daughter is responsible for his/her own safety while on the trip and that travel Agencies, WIESCO, INC., or its Directors, and teacher-chaperons are not responsible for any injuries that may occur. We, parents/guardians and our son/daughter, specifically RELEASE, DISCHARGE, HOLD HARMLESS, in advance, all of the above-named persons from any and all liabilities that may arise from the trip.
My son/daughter has and agrees to maintain throughout the entire trip, valid and suficient medical insurance. I understand that this is my responsibility and release all persons identified above from providing such insurance coverage. I further understand that the foreign country medical facilities may not accept such insurance, that any medical services must be paid for in cash, and that I am responsible for reimbursing payment and submitting my own insurance claim.
We agree that my son/daughter will accept and abide by all rules and policies imposed by WIESCO, INC. Directors or teacher-chaperons. This acknowledgement and assumption of risk and release shall be upon us, parents/guardians. We hereby consent to our son/daughter’s participation in the program.
Signature(s):___________________________ _____________________________
(Parent/ Guardian) (Parent/Guardian)
Signature:____________________________ __________________________
(Student) (Date)

Signed _______________________________
(Witness to above signatures)
________________________________
(Date)

(Please return this with your application.)