Health & Emergency Contact Form

  • Please take a few minutes to complete this Health & Emergency Contact Form in order to participate in events and trips with The Orchard. Please complete one form per participant.

  • Participant's General Information

  • Date Format: MM slash DD slash YYYY
  • If the participant is a minor under the age of 18, you must include the parent/guardian information below. If you are 18 or older, you can skip to the Emergency Contact Information section.

  • Emergency Contact Information

    Note: Include information for two people (Other than the Parent/Guardian included above)

  • Health Insurance Information

    Note: The Orchard will obtain supplemental health insurance coverage valid on location during overseas trips.

  • Health History

    Note: Indicate N/A if none.

  • First Aid and Emergency Medical Treatment

  • I recognize that there may be occasions where I or the minor participant may require first aid or emergency medical treatment. I do hereby give my consent and permission for the Team Leader(s) of The Orchard to seek and secure any necessary emergency first aid or medical treatment for me or the minor participant including hospitalization if such need arises. In doing so, I further agree to pay for all fees and costs which arise from this action.
    I give my permission for the attending physician(s) and other medical personnel to administer any necessary emergency medical treatment, including surgery, and I agree to pay for the medical treatment.

  • Date Format: MM slash DD slash YYYY
  • If the participant is a minor under the age of 18, this form must be signed by a parent or legal guardian.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.