Medical Form - Irish Life Experience

Completion of this form is required for participation in the Irish Life Experience. Please submit this form by June 1st, 2025.

Participant and Participant’s Parents Please Note:

Every item in every section must be completed.
Mark N/A if any section is not applicable to you.
Any item or section that is not completed will require written or telephone follow-up and a follow up fee.
You can avoid any additional expense of a medical follow up fee by answering the questions thoroughly.
Please supply the Irish Life Experience with a double-sided copy of the insurance card the participant is covered under.
Please supply the Irish Life Experience with a $100 medical deposit/check preferably.
Your place on the Irish Life Experience is confirmed when we receive all forms. This medical form is a particularly important way to ensure a safe and enjoyable experience for you. The physical examination must take place within twelve months of the Irish Life Experience start date.

If your child is/has been on any medication-including for ADD/ADHD, they must continue to take it while on the Irish Life Experience. The Irish Life Experience Staff will also collect and distribute all medication to students during the program to ensure that students are taking their medication on time and with the proper dosage.

By signing this, you will also grant permission to the Irish Life Experience and/or its assigns, to hospitalize, treat and order injections, anesthesia, or surgery of the child/ward. You will further authorize the Irish Life Experience to use non-prescription medicine in the event of minor injuries and/or ailments. You understand and agree to pay all costs associated with medical care and transportation, including the cost of any evacuation, treatment, or medications. All information will remain confidential. If the applicant has a pre-existing condition or injury that is not indicated on the medical form, and they are subsequently forced to leave the program because of that condition, then the applicant/parent and/or guardian, will be responsible for an exit fee and will not receive any refund.

Participant's Name

Parent's/Guardian's Name

Person other than parent to be notified

Health/Hospitalization Plan

Policy Number/Group Name

Phone of Company or Agent

Does the participant have valid overseas insurance/medical coverage?

Yes No

Medical History

High Blood Pressure

Yes No

Heart Disease

Yes No

Heart Murmur

Yes No

Irregular Heartbeat

Yes No

Family History of Heart Attack

Yes No

Tuberculosis

Yes No

Recent Exposure to TB

Yes No

Positive TB Test

Yes No

Active Hepatitis

Yes No

History of Hepatitis

Yes No

Seizure Disorder

Yes No

Seizure with the Year

Yes No

Bleeding Disorder

Yes No

Anemia/Sickle Cell Trait

Yes No

Chronic Cough

Yes No

Asthma

Yes No

Diabetes

Yes No

Hypoglycemia

Yes No

Anorexia

Yes No

Bulimia

Yes No

Cancer

Yes No

Depression

Yes No

Skin Problem

Yes No

Circulation Problem

Yes No

Headaches

Yes No

Stomach Ulcers

Yes No

Heatstroke

Yes No

Bladder Infection

Yes No

Kidney Problems

Yes No

Thyroid Problems

Yes No

Hearing Impairment

Yes No

Vision Impairment

Yes No

Motion Sickness

Yes No

Sleep Walking

Yes No

Broken Bones

Yes No

Neck Problems

Yes No

Back Problems

Yes No

Knee Problems

Yes No

Special Diet

Yes No

Dyslexia

Yes No

ADD/ADHD

Yes No

Turrets

Yes No

Medical Equipment Devices

Yes No

PMS

Yes No

If you have answered yes to any of the above items, please explain.

Allergies

Yes No

Additional Information

Medications

Yes No

Additional Information

Tetanus Immunization

Have you been in counseling with a psychiatrist, psychologist, or other counselor within the past two years?

Yes No

Are you currently in counseling/treatment?

Yes No

How long have you been seeing this counselor?

Please arrange for a release of information with your counselor so we may contact her/him. Have you done so?

Yes No

Counselor's Name

Participant's Name

Parent's Name

Address

1 Central Street
Suite 205
Middleton, MA 01949

E-Mail Address

[email protected]

Call Us

855-IRISH-LIFE

Medical Information

Address

E-Mail Address

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Trip Dates: June 29-July 23, 2025