Mission Trip Health Form

You will need to fill out this health form in order to finish your mission trip application.

Since our health forms are only active from May to May even if you have finished the health form previously, you need to do so again in order to be eligible for mission trip since they are during May and June.

2024-2025 Health Form

What is your first and last name? * required

When were you born? * required

What is your parent's first and last name? * required

What is your address? * required

Parent Cell phone

Home phone

Additional Emergency Contact

Doctor

Is this participant covered by medical insurance? * required

Yes

Insurance Name Policy Number

Please give us a scanned copy of your insurance card.

Please read and agree to the following

On this , I/we the parent(s)/legal guardian(s) of the above-named child ("Participant") do hereby delegate to the TFC Connection Staff a "Power of Attorney" for the above-named child for the purpose of having custody of my/our child and my/our consent to any needed emergency/medical treatment and administration of prescribed medications of my/our child.

In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician or dentist selected by the TFC Connection Staff to hospitalize, to secure proper treatment, and/or order any injection, anesthesia, or surgery for my son or daughter as deemed necessary.

I understand that every activity sponsored by TFC Connection is carefully planned and adequately supervised by mature adults. However, even with the best planning and precaution, unforeseen events can occur. By signing this form as parent/guardian, I/we agree to assume and accept all risks and hazards inherent in ministry-related activities and events. I/we acknowledge that participation in TFC Connection ministry activities and events involves risk to the participant (and to the participant's parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

In consideration for the opportunity to participate in TFC Connection activities and events, the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activities or events. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or event, or during transportation to and from the activity or event, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the "activity sponsor"). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of ministry activities and events, or transportation to and from activities and events, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise.

I/we also agree not to hold TFC Connection, it's employees or volunteer assistants liable for damages, losses, or injuries to the participant or their personal property. As parent/guardian, I understand that I am signing for the minor named on this form and the signatures are to provide for the medical release and the liability release.

Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action, or otherwise, I/we hereby assume transportation costs for their return.

I give permission to TFC Connection to use my child's image in photos or videos taken at TFC sponsored activities and events in order to publicize or promote TFC activities, including promotional materials, the TFC website, and social media pages.

Do you agree with the above? * required

Yes

Please list specific allergies

Treatment for those allergies

Physical or mental conditions that we should be aware of

When was your last tetanus shot?

Swimming ability

Good

Fair

None

What medication schedule do you follow?

Medication must be in it's original labeled container from the pharmacy

Please write them out in this pattern and a new medication on each line.

Medication Name	Time Given	How Many	Purpose of Medication
(Sample) Tums,	After each meal,	1-2,	Stomach issues

Is there anything you want the TFC staff to know that would help your child have a great experience?

You have not agreed to the liability release. Please have a guardian read and agree to it first.

You have not entered in your insurance name.

You have not entered in a policy number.

You have not included a copy of your insurance card.