Trip Participant Medical Information
Dates of Trip
Please Select
January 13-20, 2026
Participant Information
Name
Current Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
example@example.com
Phone Number
Date of Birth
/
Month
/
Day
Year
Date
Have you ever been on a TAP trip?
Yes
No
Role:
Team Member
Team Leader
Emergency Contact Information
Please identify an emergency contact for the above particpant who will be reachable in the United States at the time of the trip.
Name
Relationship
Phone Number
Emergency Medical Information
Please provide your medical insurance information, as well as other information that will be important in the event of an emergency.
Insurance Provider Name
Insured Member ID
Company Group Number
Other important information (such as prescribed medications, known allergies, or a pre-existing medical condition):
Submit
Should be Empty: