Emergency/Medical Form
Please fill out the form below
Email address
Last Name
Your answer
First Name
Your answer
College Year
Gender
T-Shirt Size
Your answer
Emergency Contact Info
Emergency Contact Name
Your answer
Emergency Contact Relationship
Your answer
Emergency Contact Phone Number
Your answer
Medical Information
Please Provide your medical information below.
Insurance Provider:
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Insurance Card #:
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Expiration Date:
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Insurance Phone Number:
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List ALL Medications
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Allergies
Please provide any allergies
Food:
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Medical:
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Currently Prescribed Treatments:
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Dietary Restrictions (i.e. vegetarian/vegan)
Your answer
Am I physically, mentally and emotionally prepared to participate in this trip?
Please describe any other physical, emotional, or mental health issues relating to you that staff should be aware of (kept confidential unless permission received to share with other staff as needed):
Your answer
Permission and Release
Signature below shall constitute my permission sponsored events between August 2016 and August 2017. These events may include, but are not limited to, ministry trips, retreats, games and special events. I understand that I may be transported by bus, rental van (12-passenger or less), or car driven by staff or approved adult volunteers. I hereby release and hold harmless The Gathering Campus Ministry, its personnel and leaders from any and all liability for any injuries, loss, or other claims arising out of my participation in these campus ministry sponsored events and activities. My signature below gives consent to any Gathering staff to dispense medication as indicated above. This document or a copy thereof gives consent to any Gathering staff, in an emergency to the nearest appropriate medical facility. The facility and its medical staff have authorization to provide treatment that a physician deems necessary for the well being of me.
Signature:
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Date:
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