RAC L'Taken Washington D.C. Trip 5783

Friday, December 9, 2022 • 15 Kislev 5783

All Day for 3 Days

Register

Participant Name

Participant E-mail

Participant Cell Phone #

Participant Gender and Pronouns

Emergency Contact #1 - Name

Emergency Contact #1- Email

Emergency Contact #1 - Cell Phone

Emergency Contact #2 - Name

Emergency Contact #2- Email

Emergency Contact #2- Cell Phone

Over-the-Counter Medication Release

[FOR LEGAL GUARDIANS] Do you give Jenna (and/or other Trip Chaperones) permission to provide your child with over-the-counter medications? (E.g. Advil, Tylenol) *

Participant Medication Information

Does the trip participant take any regular medication? If yes, please describe the medication, dosage amount, and time of day it should be taken.

Emergency Medical Care Release

[FOR LEGAL GUARDIANS] Do you give Jenna (and/or other Trip Chaperones) permission to seek medical care for the participant in case of an emergency? *

Additional Dietary Information

Please use this space to provide any additional information about the participant's allergies or dietary needs, as is needed (specifics, severity, etc.)

Additional Information

Is there anything else we should know about this participant?