Phoenix Children's Chorus

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Boston Tour Medical Information

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PCC Boston Tour Medical Information

The information collected in this form will be used solely for chorister, chaperone and staff safety during Boston Tour. The information is confidential and shared only with healthcare professionals on tour and relevant PCC staff members.

First Name *

Last Name *

Email Address *

Is this form for a chorister, chaperone, or staff member? *

Emergency Contact Name (first & last) *

Emergency Contact must be someone not going on tour

Emergency Contact Phone Number *

Dietary Restrictions *

I do not have any dietary restrictions

Vegetarian

Vegan

Lactose Intolerant

Lactose Sensitive

Gluten Intolerant/Celiac

Gluten Free Preference

No Shellfish

No Nuts

Something else I've communicated below

Dietary restrictions not listed above

Any food allergies? If so, what reaction?

Any medication allergies? If so, what reaction?

Any environmental allergies? If so, what reaction?

Any updated medical issues or diagnoses not listed or updated in Choir Genius?

List and explain. Type NA if it does not apply

In case of sickness or accident, we give permission for medical attention and treatment as deemed needed by healthcare professionals be administered. *

Yes

If you selected 'No' above, please explain so we know best how to help in an emergency. *

If you select 'no', a member of our medical team will be reaching out to discuss.

Check all that apply: The medical staff on duty has permission to administer the following to the above named chorister: *

Acetaminophen (Tylenol)

Ibuprofen (Advil)

Meclizine (Motion sickness)

Antibiotic Cream (Neosporin)

Benadryl (Allergy Med)

Immodium (Anti-diarrheal)

List all active prescriptions with medication name, dose, and frequency *

Acknowledgement: ANY rescue medication should always accompany the chorister for PCC travel. Rescue medication is life-saving medication such as Epi-pens, Auvi-Q, inhalers, diabetic or seizure medications.

I understand and agree that all rescue meds prescribed will go on tour. *

Yes