Mission Participant Important Form: Global Frontier Missions

The Important Form

This form is to be filled out by all GFM mission trip participants, interns, and Mission Training School students. The better the information you provide, the better prepared we will be to help you out in the event of an emergency or some other problem.

**All fields that apply to you are required!

Participant Information

Participant's Full Name (as on passport)
Participant is a...
Dates participant will be with GFM
Mission Trip Group Name (if applicable)
Mission Trip Group Leader (if applicable)
Age	Birthdate	Gender
Passport Number
Passport Expiration Date
Country passport is from
ALL U.S. and Canadian citizens MUST have a passport to travel on any of our international trips (you can ignore these fields for our domestic locations)
Address
City State/Province Zip/Postal Code
Country
Phone Number (xxx) xxx-xxxx
Alternate Phone Number (optional)
E-mail Address

Who can we contact in the event of an emergency?

Contact's First and Last Name
Relationship to You
Contact Phone # (XXX-XXX-XXXX)
Alternate Phone #
Contact E-mail Address

Alternate Emergency Contact:

Contact's First and Last Name
Relationship to You
Contact Phone # (XXX-XXX-XXXX)
Alternate Phone #
Contact E-mail Address

Participant's Medical Insurance Information

Do you have medical insurance?
Insurance Company
Group Number
Policy Number
In whose name is the insurance?

Participant's Medical Information

Please be accurate and specific!

Name of Family Doctor
City and State/Province
Doctor's Phone Number (xxx) xxx-xxxx)

Hospital and medical records for this participant are located at:

Height: feet inches Weight: pounds

Blood Type: (if known)

Please list all prescription medications you are bringing on the trip:

Medication	Dosage

Please describe any allergies you have to medications:

Please describe any other allergies you have (food, etc.):

Date of last tetanus shot:

Please describe any current or pre-existing health problems/medical conditions (i.e. migraines, asthma, chest pains, seizures, etc.):

Please describe any physical activity limitations you have:

Additional Comments :

Signature

By signing below, I affirm that I am the participant named above and am at least 18 years old, or that I am the natural parent or legal guardian of the participant named above and that I give permission for the participant to attend and participate in the Global Frontier Missions function specified above. I further affirm that the above information is true, accurate, and complete to the best of my knowledge, and I affirm that I have read and agree with the Waiver of Liability and Consent Form.

The following MUST be completed and signed by either the participant or a parent/legal guardian of the participant if participant is under the age of 18 years old:

Your Full Name
Relationship to Participant (if applicable)
Today's Date
Electronic Signature (type your full name)

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Global Frontier Missions; 954 Camp Creek Dr SW; Lilburn, GA 30047; 770-841-4833; E-mail GFM