WILSHIRE STUDENT MINISTRY 2023-2024
You'll be asked for date of last tetanus shot and upload an insurance card.
Youth's full name
Street Address Line 2
State / Province
Postal / Zip Code
Parent Cell Phone
Parent Cell Number
Please enter a valid phone number.
Please list an additional emergency contact name
Emergency contact's phone
Relationship to Youth
1. Does your youth have any medical problem such as diabetes or asthma that the sponsors should know about? If so, explain and give instructions for care.
2. Is your youth taking any medication routinely?
If so, what medication is your youth bringing on the trip?
3. Please list any food or drug allergies.
4. Provide the date (month/year) of your youth's last Tetanus shot. (Please do not list "current", medical staff will need to know a specific date.)
5. Other information you would like us to know about your youth:
6. Please upload and front back copy of an insurance card.
Drag and drop files here
Choose a file
Please click here to indicate that you are not providing insurance information:
Should be Empty: