Bosco Ministries In Montem Winter Expedition Application

Select Your Trip

School Currently Attending (Official Name), if any.

First Name

Last Name

Birthdate

Weight

Height

Address Line 1

Address Line 2

City

State

Zipcode/Postal Code

Phone

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone. Preferably mobile.

Emergency Contact Relationship to Applicant

Pertinent Non-Medical Information

Do any members of your family have a history of heart disease, diabetes, seizures, mental or emotional illnesses?

Do you have any present physical illness or disability?

Does you have a history of or currently have any emotional or mental illnesses including but not limited to: depression, anxiety, autism, Down Syndrome?

Does you have a history of behavioral problems, drug or alcohol use?

Will you be taking any medications during the time of the program?

Allergies?

Please explain all 'Yes' answers to the above list. If you requires any particular consideration, care, medication, (e.g. epipen, protective head gear for sports, etc.) please explain here.

Please note any other pertinent medical history details:

A special diet? (e.g. Allergies)

Any other special requirements we should be aware of?

If any special requirements, please list them here.

Covered by insurance?

Insurance Coverage First name

Insurance Coverage Last name

Insurance Company Name

Insurance Address 1

Insurance Address 2

Insurance Address City

Insurance State (2 Letter Abbrev.)

Insurance Zip

Insurance Policy Number

By completing this application, I acknowledge and agree to all of the terms, release, and consent available for review on the Bosco Ministries website, and required by Bosco Ministries.