This medical information may be necessary in the event of serious illness or accident. Please complete this form accurately and truthfully. The facts you disclose will be kept confidential among the Georgia Tech Stamps President's Scholar staff and Faculty Guides and the information provided will be given to others only in an emergency situation. Failure to disclose accurate and complete information could compound the seriousness of an accident or illness.

General Information

Insurance Information

Please upload a photo of your health insurance card:

Emergency Contact Information

Emergency Contact #1

Emergency Contact #2

Health Information

Please list all over-the-counter and prescription medications and what the medications are used for. Clearly indicate any for which it would be critical or life-threatening if you ran out.
Bring sufficient quantities with you to this event.

Please list all drug, severe food, and other allergies that you are aware of as well as any treatments you utilize in the event of an allergic reaction.

Please describe any medical or health condition that might affect your participation in activities or that should be made known to medical personnel incase of an emergency. This includes any restriction of activity for medical reasons.

Please describe any dietary restrictions you require.

Form Submission
I am aware of all my personal medical needs, and consulted with a medical doctor about my plans if I have any serious conditions. There are no health-related reasons or problems that might require accommodation in activities except as explained above.

Consent of Electronic Signature
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right.
I consent to an Electronic Signature

Electronic Signature of Parent or Guardian of Participant if Participant is under 18 years of age.