Short-Term Mission Trip Insurance Statement
Participant Information
Full Name
Date of Birth
Address
Phone Number
Email
Trip Information
Destination
Trip Dates
Insurance Information
Insurance Provider
Policy Number
Emergency Contact Name
Emergency Contact Phone
Coverage Details
Type of Coverage
Coverage Amount
Notes
Medical
Evacuation
Accidental Death
Other
Statement
Please confirm you have obtained appropriate insurance coverage for your participation in the mission trip, and provide any additional relevant details:
Signature
Date