Avalanche Participant Information
Personal Information
Participant's Name
*
First Name
Last Name
Participant's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the Participant over the age of 18?
*
Yes
No
Guardian's Name (If Under 18)
First Name
Last Name
Participant/Guardian's Email Address (for communication of trip details)
*
example@example.com
Which Ministry Site are you affiliated with?
*
Emergency Contact Information
In the case of an emergency, who should we contact?
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Relationship to Participant
*
Secondary Emergency Contact
First Name
Last Name
Secondary Emergency Contact Phone Number
Please enter a valid phone number.
Relationship to Participant
Medical/Insurance Information
In case of an emergency, we want to have all the important information necessary to care for the participant.
Primary Care Physician's Name
*
Primary Care Physician's Phone Number
*
Please enter a valid phone number.
Primary Care Physician's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Has the participant had a physical in the last 24 months?
*
Yes
No
Medical Insurance Company Name
*
Insurance Policy Number
*
Does the participant have any allergies? - Please list all known allergies and specify the nature of the allergic reaction.
*
Does the participant take any medications? - Please list all medications including the time of day that they take it and whether it needs to be with food or not.
*
Are there any other medical conditions or concerns that the participant has that we should be aware of?
Guardian's (or Participant over 18's) Signature
By signing you are verifying that all the information provided in this form is true and that you give permission to the participant to participate in Alive 2023.
Please Sign Here
*
Submit
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