P.O. Box 4662, Antioch CA 94509
Login
Home
About
Who We Are
Our Partners
Contact
Programs
College Tours
Events
Calendar
Upcoming Events
Donate
Full Name of Student
Date of Birth
MM slash DD slash YYYY
Has my permission to receive emergency care or treatment if deemed necessary.
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Health Insurance Plan Name
ID No
Does the student have any existing medical conditions?
YES
NO
If so, explain
Currently using medication?
YES
NO
List Medications
Is the student allergic to any medication (s)
YES
NO
List Medications
Primary Physician Name
Phone Number
*
*
It is hereby understood and agreed upon that Parents Connected, its customers and affiliates shall not be held responsible for any claims, losses, suits or actions arising out of acts of God, war, terrorism, strikes, damages or loss of baggage or other personal property, sickness, delay, change of airline flight schedule, or personal injury caused by persons not controlled by Parents Connected. Tours reserves the right to accept any person(s) as a member of the group, and to pass on to the client any Expenditures created by airline delays or other events not controlled by Parents Connected such as weather.
All and any medication will stay in possession of a designated chaperone.
Notifications