TORCH MISSIONS TRIP APPLICATION FORM

JEREMY MYERS’ TRIP:

Section 1: Contact information

First Name (as on passport):

Middle Name (as on passport):

Last Name (as on passport):

E-mail address:

Address

Street, City, State, Zip Code

Cellular Phone:

(###)

###

####

Passport number:

Passport Expiration Date

YYYY

Section 2: Personal information

Name you most often go by:

Sex:

Birth date:

YYYY

Age:

Check one:

Foreign languages studied:

Have you ever been on a mission trip? If yes, where and when?:

Names of home Church:

Shirt size:

Small

Medium

Large

X-Large

2XL

3XL

4XL

Section 3: Medical history and information

Emergency contact:

First Name

Last Name

Emergency contact telephone:

(###)

###

####

Additional contact:

First Name

Last Name

Additional contact telephone:

(###)

###

####

Physician:

First Name

Last Name

Physician telephone:

(###)

###

####

Insurance company:

Insurance company telephone:

(###)

###

####

Policy number/information:

Physical condition:

Vaccinated for COVID

List any medical or physical conditions:

List any medications your are taking:

List any allergies:

List anything else your would like us to know:

CONSENT FORM

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