Chaperone Information - Life Defenders Bus Trip 2018
By filing this out, I acknowledge that I have read and understand the description of this event, and I grant permission for emergency medical treatment on the recommendation of two medical doctors. I release Allen County Right to Life Educational Trust Fund and all other sponsors and staff from any liability resulting from illness or injury. I also acknowledge that I am traveling as a chaperone of the students on this trip and that I am expected to act in accordance with the mission of Allen county Right to Life and in the best interests of the students participating in the trip. I also agree to having a background check completed by Allen County Right to Life if no background check has been completed in the last 5 years by Allen County Right to Life or another participating organization.

Thanks for coming with us!

First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
City, State, Zip *
Your answer
Cell Phone Number - will be used to contact you while we are in Washington DC *
Your answer
Email Address *
Your answer
Date of Birth *
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First Choice Sweatshirt Size
Second Choice Sweatshirt Size
Group/Student Affiliation *
Your answer
Allergies/Dietary Restrictions
Your answer
Current Medications
Your answer
Physician's Name *
Your answer
Physician's Phone Number *
Your answer
Medical Insurance Company *
Your answer
Policy Number *
Your answer
Emergency Contact and Number *
Your answer
Chaperone "Signature" *
Your answer
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