MEDICAL AUTHORIZATION & INFORMATION

In order to participate in an Envision program, the following Emergency Medical Authorization must be signed by a parent, guardian,
or legal representative. Sign and upload this completed form to your MyEnvisionExperience.com page. If you do not submit this form
online, you must bring a signed printed copy with you on arrival day. Please be aware that a signed Medical Authorization & Information
form is necessary to participate in any program activities. This information is kept strictly confidential and will be disclosed only to
individuals responsible for any medical care or treatment your student may require.

Many of our venue partners are currently requiring testing for COVID-19 upon arrival at the program venue. If such testing is required,
by signing below, you are consenting to such testing. If required COVID-19 testing is refused, or the test is positive, the student named
below will not be allowed to participate in the program and will be sent home at the Parent/Guardian/Legal Representative’s sole
expense. Transfer options for future sessions or summer 2022 may be available.

Student’s Full Name: Vitela Braelynn J

Last Name First Name Middle Initial

Student Contact Information (optional – but recommended): In the unlikely event of an emergency, it is helpful for us to have your
student’s personal contact information to distribute important information via text or email.

Student Mobile Phone: Student Email Address:

Emergency Medical Authorization (Must be completed for primary and secondary contacts.)
I authorize Envision and its agents to seek medical treatment for the student named above and to sign, on my behalf, as guarantor of
payment of any medical treatment that may be required.

Parent/Guardian/Legal Representative’s Name:

Vitela Chris
Last Name First Name

Home Address: 1713 w highway 50 lot 145B Ofallon IL 62269

Primary Phone: (314)677-4072 Secondary Phone:

Signature of Parent/Guardian/Legal Representative: Date: 05/16/2021

Secondary Emergency Contact: This contact should be someone who does not reside at the student’s home address.

Vitela Matthew
Full Name Relationship to Student

Primary Phone: (314)488-0077 Secondary Phone:

Medical Information
Please provide the following medical information that should be considered if medical treatment is required for the
above-named student. Include an additional sheet if more space is needed.

List any health or psychological conditions, Needs glasses for reading and screen time.
mobility limitations, sight/hearing limitations
or any other medical conditions. Please also
include the severity of the condition:
List any medications that the student is
currently taking:

List any food/medication allergies:

Allergic to amoxicillin.
List any dietary requirements:

Questions? Call the Office of Admissions at 877-587-9659 or 703-584-9513