You’ll probably want everyone in your group to complete the following form before departure. It is advisable that you take a copy with you and leave another on file at your church. Be mindful that you are asking personal information that should remain confidential unless an emergency situation requires you to use it.

Health Information Sheet

Your name : _____________________________________________________________

Your address: ___________________________________________________________

_________________________________________________________________________

Your home phone: ____________________ cell: _____________________________

Health Insurance Company: Insurance #: ___________________________________

Your Primary Doctor's Name: _____________________________________________

Phone number: ___________________________________________________________

Please list any medications you will be taking with you on the trip:

In case of Emergency:

Please contact: Name: ___________________________________________________

Relationship to you: ____________________________________________________

Phone: ________________________________

Other phone: __________________________

Special Diet Concerns (we need to be aware of):

Any other information we should know before departure?