Church Outbound Mission Trip Consent Form
Participant Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Parent/Guardian Information (if participant is under 18)
Name
Phone Number
Email Address
Emergency Contact
Name
Relationship
Phone Number
Medical Information
Medical Conditions / Allergies
Current Medications
Health Insurance Provider & Policy Number
Primary Physician Name & Phone
Mission Trip Details
Destination
Trip Dates
Consent & Acknowledgement
By signing below, I acknowledge that I have read and understood the details of this mission trip, and consent to participate (or consent for my child to participate). I authorize medical care in case of emergency, and release the church and its representatives from liability.
Signature
Date