Appalachia Adult Participant Form

Appalachia Adult Participant Form

Required for all Appalachia mission trip participants 18 years of age and older. (If you are over 18, but still utilizing family/parent health insurance, please submit the Youth Participant Form.)
Please complete the form in its entirety. For any fields that do not apply to you, please enter "N/A."
Church/Group Name*
Trip Start Date*

MonthDayYear
Date
Participant Information
Participant Full Name*
Nickname
Please enter the name you typically go by
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Mobile Number*
Please enter a valid phone number.
Secondary Number
Please enter a valid phone number.
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Contact Name*

First NameLast Name
Relationship to Participant*
Contact Mobile Phone #*
Please enter a valid phone number.
Contact Alt Phone #*
Please enter a valid phone number.
Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Provider / Insurance Information

* Health Insurance is Required for all Trip Participants *
Name of Insurance Carrier*
Insurance Policy #*
Name of Policy Holder*

First NameLast Name
Please upload a copy of your Insurance Card*

Cancelof
Health Conditions & Current Medications
Please list all prescribed and over-the-counter medications you are currently taking. Enter "N/A" if not applicable.*
Please list any allergies, including medicine, food and insect allergies. Enter "N/A" if not applicable.*
Please enter the date of your most recent Tetanus immunization. (If unknown, please leave blank.)

MonthDayYear
Date
Please check any of the conditions or symptoms listed below that you have, are being treated for, or have had in the past five years. If none apply then click "N/A".*

N/AHigh Blood PressureHeart DiseaseHeart MurmurIrregular Heart BeatTuberculosisHepatitisEpilepsyBleeding DisorderAnemiaAsthmaDiabetesHypoglycemiaAnorexia/BulimiaCancerSkin ProblemsFrostbite/Cold ToleranceCirculation ConcernsBroken BonesArm/Shoulder IssuesKnee/Ankle IssuesLeg/Feet IssuesHeadachesHead InjuryNeurological ConcernsJaundiceHeat Intolerance/Heat StrokeBladder IssuesKidney IssuesThyroid IssuesEndocrine IssuesHearing ImpairmentVision ImpairmentWheelchair BoundMotion SicknessSleep WalkingCurrently PregnantSpecial Dietary RequirementsLearning DisabilityMedical Equipment NeedsStomach UlcersIntestinal IssuesActive BedwettingChest PainHeart PalpitationsUnexplained SweatingShortness of BreathDizzinessFainting SpellsCramping IssuesADD/ADHDNeurodivergent
Please list any checked medical issue and provide the frequency, duration, treatment, date of last occurrence, and any other relevant information in the space provided.*
Please number each issue individually
CrossRoads Missions - Appalachia Code of Conduct
CrossRoads Missions - Appalachia Principles & Guidelines
CrossRoads Missions - Appalachia Participant Agreement
Participant's Printed Name*
Please Type Your Name
Signature*

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Appalachia Adult Participant Form

Participant Information

Emergency Contact Information

Health Provider / Insurance Information

Health Conditions & Current Medications

CrossRoads Missions - Appalachia Code of Conduct

CrossRoads Missions - Appalachia Principles & Guidelines

CrossRoads Missions - Appalachia Participant Agreement