Shirts Across America · 2022 Airline & Medical Form

Adult Volunteer Information

Full/Formal Name (as appears on ID)

*

First Name

Last Name

Preferred Name

Your nickname is applicable.

Personal Email

*

Email that will receive confirmation of this form submission.

Verify Email

*

Cell Phone

Best phone number to reach Participant.

Birthdate (MM/DD/YYYY).

*

(mm/dd/yyyy)

Gender

*

This is what is indicated on your identification or passport.

Medical Information

Insurance Provider

*

Policy Number

*

Primary Doctor's Name

*

Primary Doctor's Phone Number

*

Do you have asthma, respiratory condition(s) or allergies to mold?

*

Do you have a history of reactions to heat?

*

Do you have diabetes?

*

Do you have a history of seizures?

*

Dietary Restrictions

*

No Dietary Restrictions

Dairy Free

Gluten Free

Peanut Allergy

Pescatarian (no animal products, but will eat fish)

Vegan (no animal products)

Vegetarian (no animal meat)

Other (please elaborate below)

If you answered NO Above- please type "N/A" in field below.
If you answered Yes - Please elaborate on any other allergies, medications or particular health concerns/needs you may have:

*

Emergency Contact Information

Primary Emergency Contact Name

*

First Name

Last Name

Primary Emergency Contact Phone

*

Will your emergency contact person be traveling and away from home while you are in New Orleans?

*

Secondary Emergency Contact Name

First Name

Last Name

Secondary Emergency Contact Phone

If they will be traveling, please provide any helpful details here:

Helpful information includes location of travel, additional contact information if destination is abroad, etc.

Adult ParticipantAirline & Medical Information

Adult Volunteer Information

Medical Information

Emergency Contact Information

Adult Participant
Airline & Medical Information