Personal Information Form

Name

First

Last

Badge Name

(FIRST NAME ONLY or NICKNAME for Trip Name Tag)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (If Different From Above)

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email

Occupation

Retired

Yes
No

Church Information (If Applicable)

Church Name

Church City/State

Church Phone (Include Area Code)

Church Responsibilities/Duties (If Any)

Voluntary Group Participation

What particular talents do you have that, if called upon, you would be willing to share with the group?

Dancing/Singing
Ministry/Preaching
Training/Teaching
Other Talents to share

If answered "Other" above, please explain

Medical Information

It is important for us to be aware of any information that could help in case of an emergency. Are you affected by any of the following? (Check all that apply, and elaborate if needed)

Have you received a Covid Vaccine and are up to date?

Yes
No

Checkboxes

If you checked any of the above, please explain further, please indicate how this may affect you during this trip and what, if any, medications you will be using to control any health issues:

Are there any other concerns or issues, medically or otherwise, we may need to know about you? If yes, please explain:

To the best of your knowledge, are you medically able to travel on this trip?

Yes
No

Typically, our trips include a lot of walking, and sometimes up and down steps. Are you able to walk and climb stairs, if necessary?

Yes
No

If you are limited in your mobility, will you be willing to skip some of the more strenuous tours, if necessary, on the trip?

Yes
No

Are you wheelchair-dependent?

Yes
No

Will you need the use of a wheelchair at the airports only?

Yes
No

Physician's Name (If Applicable)

Physician's City/State

Physician's Phone

Emergency Contact Information

Primary Contact Name

First

Last

Relationship

City/State

Phone (Include Area Code)

Secondary Contact Name

First

Last

Relationship

City/State

Phone (Include Area Code)