New Orleans Youth Participant Form

New Orleans Youth Participant Form

Completion of this form is required for each New Orleans mission trip participant under 18 years of age OR if still utilizing family/parent health insurance.
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
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Father/Guardian Name

First NameLast Name
Father/Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father/Guardian Email
example@example.com
Father/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother/Guardian Name

First NameLast Name
Mother/Guardian Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother/Guardian Email
example@example.com
Mother/Guardian 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.Format: (000) 000-0000.
Contact Alt Phone #
Please enter a valid phone number.Format: (000) 000-0000.
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.

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".
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 - New Orleans Code of Conduct
CrossRoads Missions - New Orleans Principles & Guidelines
CrossRoads Missions - New Orleans Participant Agreement
Participant's Printed Name
Please Type Your Name
Signature

By signing this document, I acknowledge that all the information I have provided is true, and I understand that my electronic signature is legally binding.
Should be Empty:

New Orleans Youth Participant Form

Participant Information

Parent/Guardian Information

Emergency Contact Information

Health Provider / Insurance Information

Health Conditions & Current Medications

CrossRoads Missions - New Orleans Code of Conduct

CrossRoads Missions - New Orleans Principles & Guidelines

CrossRoads Missions - New Orleans Participant Agreement