Name

First

Last

Parent/Guardian Name

First

Last

Please Specify Relationship to Traveler:

Mother, Grandfather, Nanny, etc.

Email

Travel Information

Travel Destination

Destination Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Departure

Date of Return

Traveler’s Information

Date of Birth

Current Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Does the traveler have any medical conditions?

Please provide details of all medical conditions

Please provide details of medication that the traveler should carry

Are there any known allergies?

Please provide details of all known allergies

Does the traveler carry an Epi-Pen or similar device?

Yes
No

Are there any specific dietary requirements not covered above?

Please provide details of dietary requirements

If other, please describe below

Emergency Contact Information

Emergency Contact Name

First

Last

Phone

Email

Consent

I agree that the above mentioned traveler may:

Take part in the trip detailed above
Be given first aid or urgent medical treatment in any event

Signature

Clear Signature

Stimpunks Foundation

Travel Consent Form

▶ Table of Contents

Travel Information

Traveler’s Information

Emergency Contact Information

Consent