Health Insurance Please Note: This form must be completed prior to participating in the program. If we do not get this form you will NOT be allowed to participate in the week’s activities. Youth Mission Participant: Insurance Provider Details Are you (or your child) covered by Health Insurance?(Required)YESNOHealth Insurance Provider Name of Primary Insurance Holder Policy Number If applicable, Group ID# Type of Insurance PPO/HMO EPO POS Medicare/Medicaid Short Term or COBRA plan Other Prescription Health Plan (if different from primary provider) Name of Emergency Contact(Required) Phone Number of Emergency Contact (Mobile or Home)(Required)Emergency Contact Alternate Phone Number (Home, Work, etc.)Relationship to Participant Parent/Guardian Spouse Family Member (sibling, son/daughter, cousin, etc.) Close Friend / Non-Family Other Δ
