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Youth Tour Chaperone Info Form

 

 

FILL out the Identi-Check BACKGROUND FORM and email back to Kristin Banks: kbanks@aiec.coop – CLICK HERE

 

Gather address info

(City and State/or Country of Birth)
if you do not have a home land line - enter N/A
No Spaces (ex: Los Angeles = LosAngeles)

Washington Youth Tour -- Emergency Contact

List the names and telephone numbers of two individuals NOT on the trip, who can be contacted in case of an emergency.
Contact 1
Contact 1
Contact 1
Contact 2
Contact 2
Contact 2
Contact 2

Washington Youth Tour -- Medical Information

List any allergies for which you take medication, or any other medical condition for which medication would be needed for the trip (i.e. diabetes, car sickness, pregnancy, etc.). Also, please list any chronic or temporary medical conditions (such as pregnancy, epilepsy, diabetes, etc.) that the tour director and chaperones should be aware of.
If a new medical condition occurs prior to Youth Tour contact Kristin Banks: kbanks@oldsite.aiec.coop or call 217-241-7924.
IF APPLICABLE Do you have any of the following:
If you have a religious dietary restriction please list here

Washington Youth Tour -- Insurance Data

Note: This information is required for the Accidental Insurance Coverage provided by the AIEC.

** Print the Chaperone Medical Release (must be NOTARIZED) form. Return the signed/notarized form to Kristin Banks by April 27, 2018. **