2021 Cohort Additional Information – NC Institute for Spiritual Direction and Formation

Please fill out this additional information form. Insert “none” for any applicable areas. Contact Khris Ford if you need to discuss any information privately.

Additional Information

Name(Required)

First Last

Emergency Contact(Required)

First Last

Emergency Contact Phone(Required)

Best phone contact number

Alternate Emergency Contact

A person to contact in case your original person is not available.

First Last

Alternate Emergency Contact Phone

Best phone contact number

Dietary Restrictions

Please let us know if any of these change.

Medical Information

Physician Name

Physician Phone Number

List all medications you are currently taking

List any medications you are allergic to.

You may also list any other severe allergies you have that we should be aware of.

Please list any other medical information that you feel would be important for us to know:

Upload your COVID vaccination card

Please scan both the front and back

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