Winnsboro Trip Interest

Winnsboro, LA Health Fair Interest Form

Fill out the form carefully for registration
Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Mobile Number
Phone Number
Work Number
Emergency Contact (name, relationship, phone number)
BNF Member?

YesNo
If not a BNF member, name and relationship of BNF member you are accompanying on this trip.
Medical Profession

NPRNLPNOther
Please specify if "other"
Area of professional experience
Church & Spiritual
Name and city/state of church where you are a member
Pastor & Pastor's email address
List the roles you have held in the church
Share your testimony of salvation
Please list any mission trip(s) you have been on
Please list any ministry/child safety certifications you have completed in the last 2 years.
Health History
Please list any allergies to medication, food, etc.
Please list any significant medical history
Please provide your health insurance information
By submitting this application you agree to the following:

· A background check. The form will be emailed to you in the coming weeks.

· Attend at least 75% of planning zoom meetings (dates and times to be determined)

Contact Sherri Chatman (sherrichatman6@gmail.com) for questions or more information
Should be Empty:

Winnsboro, LA Health Fair Interest Form