Explore America

TRAVELER ALLERGY AND MEDICAL PROFILE FORM

Fill out this form completely and accurately and return it to your Group Leader in a timely manner.
This form helps ensure that your Group Leader is aware of relevant medical information so they are able to address any
situations that may arise on tour.

Traveler Information

Traveler’s name

Parent/legal guardian name

Allergies

Is your child allergic to any medication, food, etc.? What is the severity of their allergy? What should be done in case of a
reaction? (EpiPen, inhaler, etc.)

Medical conditions

Does your child suffer from any pre-existing medical conditions (seizures, diabetes, mental health issues, eating disorders,
etc.)? What are the warning signs that the Group Leader should be aware of, and what should be done in case of emergency?

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Prescription medication

Does your child take any prescription medications? If so, please list prescriptions and dosage information.

Over-the-counter medication

Are there any restrictions on over-the-counter medicine that the Group Leader should be aware of? (Benadryl, Tylenol, etc.)

Special needs

Does your child require any special accommodations on tour? (wheelchair, interpreter, etc.)

Any other information

Is there any other information about your child’s health or medical history that should be conveyed to the Group Leader prior to
the tour? If so, please list here.

Parent/legal guardian signature Date

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