Youth Mission Participant Information Form

Name of Participant(Required)

Address of Participant(Required)

Street Address Address Line 2 City State ZIP Code

Does the Participant own or carry a Mobile Phone?(Required)

Mobile Phone Number of Participant (if applicable)

Mobile Phone Number of Parent/Guardian (if participant is under 18)

This is essential for immediate contact in case of emergency, or to provide updates and ETA when returning from travel on Friday, June 30; and to provide general information if necessary.

Dietary Preferences(Required)

No Restrictions

Vegetarian

Vegan

Pescatarian

Gluten Sensitivity

Other

Do you (or your child, if under 18) have any serious allergies?(Required)

Allergies

Please list all known or diagnosed allergies, and indicate the seriousness of each, please.

Do you (or your child) have any recent injuries or medical restrictions we should know about?(Required)

Please detail information about recent injuries or medical issues :

Are you (or your child) taking any medications daily?(Required)

If the answer is yes, do they need the prescription held for them, or be reminded to take meds?

We do not recommend taking children off of usual medication regimens while they are on the Mission, unless this is under the advice of your/their physician.

Additional Information

Please use this space to describe any recent difficulties or issues you/your child have dealt with recently -- particularly pastoral issues, such as academic, family or interpersonal challenges.