Agreement Entry

Missions Trip - Medical Form

This form will take approximetly 15 minutes to complete. You will need your health insurance and medical information. You will not be able to save and return. Please complete this form in one sitting.

Personal Information

First Name

Last Name

Mobile Number

Gender

Birthdate

Medical Information

Health Insurance Company: (If you do not have health insurance, enter "N/A"

Policy/Group Number: (If you do not have health insurance, enter "N/A"

List any allergies that you have. If you do not have any allergies, enter "N/A".

List any conditions that may require special care, medication, or diet. If you do not have any conditions that require special care, enter "N/A".

Check any of the following conditions that you have or are subject to:

ADHD Asthma Heart Trouble Contact Lenses Diabetes Fainting Spells Bleeding Disorders Other None of the Above

If you checked "other" above, use the space below to give details. If you did not check "other", enter "N/A".

Are you aware of any current health issues? If so, please explain.

Are you currently under a doctor's care? This includes doctors of any kind. If so, please explain.

Do you have an up to date tetanus?

Date of most recent physical exam:

Click Next to continue on to sign the Participation Agreement, Covid Risk Assessment and Team Covenant.