LABOR-RELIGION DELEGATION TO THE BORDER
PARTICIPANT INFORMATION DOCUMENT
Please print, complete and return this application to us by surface mail: International Project, NYS Labor-Religion Coalition, 800 Troy-Schenectady Rd. , Latham, NY 12110-2455. Call us at 518/ 213-6000, ext. 6294 for more information.THANK YOU!!
I. PERSONAL DATA
1. Name: ______________________________________________________
(exactly as it appears on your identification, please)
2. Address: _______________________________________
City: _________________________ State: __________ Zip:_________
3. Telephone: (day)_____________ (eve) ______________ (fax) ___________
4. Email: _______________________ 5. Cell phone: __________________
5. Date of Birth: ________________ 6. Occupation: ________________
7. School (if applicable): ___________________ Grade/Year: _____________
8. Passport Number:___________________________
Date/Place of Issue__________________________
You MUST have a passport for travel to Mexico and to return to the United Statew. You can apply for a passport at most Post Offices. If you have any questions, please email Maureen (maureenc@labor-religion.org) or call her at 518/ 213-6000, ext. 6247.
9. Non-smoker: _________________ Smoker: ______________
10. Dietary needs: Vegetarian _________ Vegan:_________
Other special diet needs:___________________________________________
PLEASE NOTE: All dietary needs may not be able to be met. We will do our best to accommodate, but please be prepared with supplies of needed food items.
11. T-shirt size: small medium large x-large xx-large
12. T-shirt color preference:
red
blue
black
PLEASE NOTE: Colors may be substituted depending on availability.
13. Please rate your comfort with understanding and speaking Spanish:
No comfort; no ability
I understand a little
High school Spanish classes
Understand a lot and speak some
Comfortable listening and speaking
Fluent
II. CONTACT INFORMATION
14. Emergency Contact Person: _________________________________________
This is the person we will call in the unlikely event of an emergency during the delegation.
Relationship to you: _____________________________________________
Telephone: DAY: _________________ EVENING: ___________________
CELL: __________________________
15. Personal Reference: _____________________________________________
Relationship to you: _________________________________________
Telephone: day: _______________ eve: ________________________
16. Delegation dates you are interested in: _____________________________
Is another time possible for you? _________________
III. AFILIATIONS and CONTACTS
17. Please list affiliations, communities or groups you belong to, schools, clubs, etc. with whom you will be sharing your experience when you return home:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
IV. HEALTH INFORMATION
We ask this information in order that we can plan for any special needs of delegation members. Your answers to any questions will not necessarily affect your eligibility or ability to participate in the delegation but can help us to take measures to reduce the risks of serious health concerns during the course of the delegation. Please note that the Labor Religion Coalition of New York State is not responsible for health emergencies that may occur during your delegation experience.
Please check with your health care provider or insurance carrier to ensure that you have health coverage during your travel.
18. General Health: Excellent: _______ Good: _______ Fair: _______
19. Please list any chronic health problems (i.e. diabetes, heart condition, disabilities, asthma), and other health-related concerns: ___________________________________________________________
20. Please list any allergies you are aware of.
MEDICATIONS: _________________________________________________
FOODS: _______________________________________________________
OTHER: _______________________________________________________
21. Are you currently under a physician’s care or taking any prescription medication? Please describe: ______________________________________________________________
PLEASE NOTE: Be sure to bring enough of any prescription medicines with you on the delegation, in their original containers which lists your health care provider’s name. It’s also a good idea to bring a paper copy of any essential prescriptions.
22. Health insurer:______________________________________________
Primary insurance holder:_________________________________________
Health insurance member number or code: __________________________
Group number (if applicable):___________________
Primary physician's name and phone number: ________________________
______________________________________________________________
No immunizations are required for travel to Mexico. Please be sure, however,that your Tetanus immunization is up to date. In addition, you may want to discuss Hepatitis A vaccine with your health care provider.
SIGNATURE: _______________________________ DATE: ________
Rev. 04/08