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Senior Stars Trip Form for 2024
Year: 2024
Senior Stars Trips for 2024
Contact us at (828) 324-7267
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Email *
Full Name *
Phone Number *
Email *
In Case of an Emergency Who do we Contact *
Name and Phone Number of Emergency Contact *
Have you been hospitalized in the last 12 months?
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Are you suffering from a medical condition, illness, or injury?
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Required
If so, Please tell us what is going on with your health
I understand that, in the event medical treatment is required, every effort will be made to contact my emergency person. However, if they cannot be reached, I give my permission to the staff or sponsor to secure the services of a licensed physician to provide the care necessary, including surgery or anesthesia, for my well being. I will not hold Winkler's Grove Baptist Church or the members or sponsors responsible for injuries or accidents that might occur.
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List any allergies, medical problems, or any other important information we may need to know on our trips for 2023.
MEDICATIONS WITH MG AND DOSAGES
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MEDICATIONS WITH MG AND DOSAGES Continued
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Date you filled out this form *
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Insurance Company and Policy # *
Please Sign this Form *
A copy of your responses will be emailed to the address you provided.
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