Shoeboxes for Appalachia

Participant Name

First Name

Last Name

Allergies / Restrictions

Is the participant listed above allergic to any medications, foods, environmental, or other substances?

Yes

If yes, please list allergen(s):

Is the participant listed above currently on any medications?

Yes

If yes, please describe:

Emergency Contacts

Please list anyone (parent/guardian and others) authorized to act on your behalf in the event of an emergency.

Please list phone numbers in the order we should call.

INFORMED CONSENT & AUTHORIZATION for EMERGENCY TREATMENT and TRANSPORTATION Section

1. I understand that I will be notified if the participant listed on this form, becomes injured and/or ill while attending this trip.
2. In case of an emergency or when I cannot be reached, I hereby give authorization to contact other emergency contact people listed on this form. If no one listed on this form can be reached, then I hereby give authorization to the FBC Leaders and the treating physician to obtain or provide whatever medical treatment and/or transportation deemed necessary for the immediate welfare of the participant, listed above.

Condition of Registration:

I have read, understand and agree to the terms and conditions listed on this Emergency Contact Form and I understand it is my responsibility to provide accident and health insurance coverage for listed participant and I will be financially responsible for all charges and fees for emergency medical treatment and/or transportation, regardless of whether my medical insurance covers such charges and fees.

Parent/Guardian or Participant Signature (Enter Name)

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Mission Trip Registration