ACF Travel Forms
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General Information
Full Legal Name
Do you give ACF permission to use your name, primary phone number, and email address with the trip participants for this specific trip?
Do you give ACF permission to use your name and picture on ACF promotional materials?
Medical Information
List any chronic health problems:
List any physical limitations (climbing stairs, back fatigue, etc.):
List any medicinal allergies:
List any food allergies:
List the medications you are currently taking:
Date of last tetanus shot (if known):
e.g., April 2012
Primary Health Insurance Provider
Primary Health Insurance Provider phone number
Primary Health Insurance Provider Policy/Group #
Beneficiary Info
Full Legal Name
Home Address (include city, state, ZIP)
Primary Phone Number
In Case Of Emergency Contact
Full Name
Phone Number:
Alternate Contact
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