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Health & Emergency Information Form

Personal Information

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Emergency Contact

Can we contact this person via WhatsApp?

Medical Insurance

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Does your insurance provide coverage outside the U.S.?

Travel insurance note: 


When you purchase your airline ticket to Cuba, a portion of the ticket cost provides basic medical insurance while you are there. Please keep your boarding pass with you throughout the visit, as proof medical insurance.
The information above is for coverage beyond that basic benefit.

Allergies

Do you have any allergies?
If yes, what allergies?

Dietary Restrictions

Do you have any dietary restrictions or food needs we should know about?

Health Information

Are there any health conditions, recent surgeries, physical limitations, sleep issures, or other medical needs our health point person should know about?

Medications

Additional Information

Do you need disability access?

* Information required

CPN Annual Gathering 2025

Together at the Table

First Presbyterian Church Fort Worth, TX    October 2 – 5,  2025
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