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Mission Trip Adult Med Form 2013

The document is a medical information form for a youth mission trip from July 20-27, 2013 requiring personal information, emergency contacts, medical history including allergies and current medications, insurance information, and t-shirt size from participants. The form collects contact details, health issues, insurance coverage, and dietary restrictions to ensure participants' well-being during the trip.

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Corpus Christi Church
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32 views1 page

Mission Trip Adult Med Form 2013

The document is a medical information form for a youth mission trip from July 20-27, 2013 requiring personal information, emergency contacts, medical history including allergies and current medications, insurance information, and t-shirt size from participants. The form collects contact details, health issues, insurance coverage, and dietary restrictions to ensure participants' well-being during the trip.

Uploaded by

Corpus Christi Church
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Corpus Christi Church___________________________

Youth Ministry Office


1415 W. Lies Road
Carol Stream, Illinois 60188

630-483-4226
[email protected]

COLLEGE/ADULT MEDICAL INFORMATION FORM


Mission Trip
July 20 27, 2013
Personal Information
Name: ____________________________________________ Date of Birth:______________________
Address_____________________________________________________________________________
Street

City

Zip

Phone #s:___________________________________________________________________________
Email Address:____________________________________________________________________
Emergency Contact Name and Number:_________________________________________________
Allergies and Medical History
Allergic to medication/other?

No____

Yes_____

If yes, please describe:


Medications presently taking: ___________________________________________________________
Please list other Health Problems and Describe (use additional paper, if necessary)
Problem
Description

Insurance Information
Policy in the name of __________________________________________________________________
Insurance Company ___________________________________________________________________
Policy Number _______________________________________________________________________
Identification Number and/or Social Security Number ________________________________________
Authorized Physician __________________________________________________________________
Physicians Phone # ___________________________________________________________________
NOTE: Please attach a photocopy of your insurance card(s)
Mission Trip T-Shirt Size: S

XL

2XL

Other_________________

Please indicate any dietary restrictions: _________________________________________________

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