Geauga Christian Youth Missions
Information and Medical Release Form
Name: _______________________________________________ Birthdate: _____________
Address: _____________________________________________________________________
_____________________________________________________________________
Home Phone: ___________________ Cell Phone: _____________________ T-Shirt Size: ____
Email Address: ________________________________________________________________
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If you will be driving on the trip: Driver’s License #: __________________________ State Issued: __________
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Employer: ________________________________________________ Occupation: ______________________________
Church Name: _____________________________________________________________ Phone: __________________
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In case of emergency contact:
Name: __________________________________________________________________ Home Phone: ______________
Address: ________________________________________________________________ Cell Phone: ________________
________________________________________________________________ Relationship: _______________
Email Address: ___________________________________________________________
Other relative or responsible person:
Name: __________________________________________________________________ Home Phone: ______________
Address: ________________________________________________________________ Cell Phone: ________________
________________________________________________________________ Relationship: _______________
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Medical Information:
Date of last Tetanus shot: __________________ Medications you cannot take: ________________________________
Medications currently taking: _________________________________________________________________________
Allergies/special health/behavioral problems or concerns:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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Insurance Information:
Insurance Co: __________________________________________________________________ Phone: _____________
Address: __________________________________________________________________________________________
___________________________________________________________________________________________
Policy #: ___________________________________________ Policy Holder’s Ident # ____________________________
Doctor’s Name: ___________________________________________________ Phone: _________________
Rev. 2022