2023 Impact Trip Profile & Release (Adults)

2024 Impact Trip Profile & Release (Adults)

A form must be submitted for each traveler.
Traveler's Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Traveler's Gender
Traveler's Birth Date*

MonthDayYear
Date
Telephone for FoNA Communications*

Area CodePhone Number
Email for FoNA Communications*
example@example.com
Traveler Passport Number*
Passport Expiration Date*

MonthDayYear
Date
Please upload an image of your passport

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Not Required Cancelof

Medical Release Form

This section collects medical information designed to assist FoNA when seeking authorized medical treatment for you should that become necessary during the FoNA Impact Trip.
Emergency Contact Name & Relationship to You*
Nancy Johnson - Mother
Emergency Contact Preferred Number*

Area CodePhone Number
Emergency Contact Secondary Number

Area CodePhone Number
Primary Physician*
Physician Phone Number*

Area CodePhone Number
Physician's Address
Insurance Company*
Insurance Phone Number*

Area CodePhone Number
Insurance Policy Number*
Insurance Group Number*
Name of Insured*
Upload an image of your Insurance Card

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Your Health History
Please explain any physical limitations that would hinder your ability to participate in vigorous activities. *
If none, please indicate
Please describe any medical conditions or concerns you may have.*
If none, please indicate
Please list any food, medication, or environmental allergies you may have. *
If none, please indicate
My immunizations for international travel are up-to-date, including tetanus vaccine:
Consent For Treatment

I agree to notify FoNA personnel of any pre-trip injury or illness that may require medical attention or assistance during the FoNA Impact Trip.

If an emergency arises while particpating in the FoNA Impact Trip, I recognize that medical treatment may be necessary.

In case of an emergency, I give permission to FoNA personnel to secure medical attention and treatment. This may include selection of medical professionals, hospitalization, and treatment options such as injections, anesthesia, and surgery. I agree to bear the cost of this treatment.

I agree to assume all risks related to seeking and receiving medical treatment. I also agree to hold harmless FoNA and its partners from all liabilities, claims, demands, and causes of action that may arise from my participation in the FoNA Impact Trip.

Media Release

From time to time, FoNA will record activities during the FoNA Impact Trip. Recording methods could include film, videotape, magnetic tape, digital or other recording medium. These recording may be duplicated and distrubuted to the public.
I agree to the Consent For Treatment statements above.*
I agree to allow my likeness and name to be used in the promotion of FoNA endeavors.*

YesNoOther

FoNA General Liability Release

I release and agree to hold harmelss FoNA and any related agency or partner from liability, injury damages loss, accidents, delay or irregularity related to the my participation or involvement in FoNA Impact Trip.

I have been advised and understand that the FoNA Impact Trip may involve unusual risks to participants. These risks may include dangers related to air, land, and sea travel, disease, civil insurrection or warfare, post warfare hazards, and exposure to extreme heat and humidity with no air conditioning available.

I understand that this list of potential dangers is not exhaustive, rather, it is illustrative of the types of danger that could be encountered.

I understand that this release binds me, my heirs, representatives, and assignees.
I agree to the FoNA General Liability Release statements above.*

Good News!!!

You are nearly finished . . .
My signature below confirms my agreement with the following statements:*

I will promptly notify FoNA personnel If information I've disclosed on this form changes before or during the FoNA Impact Trip.By submitting this form, I agree that the information provided is true and accurate to the best of my ability.I agree to hold harmless FoNA and its partners from all liabilities, claims, demands, and causes of action that may arise from my participation in the FoNA Impact Trip.I have submitted or will submit a Power of Attorney medical form.
Signature*

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2024 Impact Trip Profile & Release (Adults)