2026 Medical and Insurance Information: Adults

2026 NCF-Envirothon Mississippi Competition
July 19 - 25, 2026

NCF-Envirothon is committed to respecting the privacy of our students, advisors, and guests. The information provided below will remain confidential and only shared with key individuals (i.e., legal guardians, team advisor/chaperone, emergency contact, medical personal, etc.) in the case of medical emergencies or illness.

Medical & Insurance Information and Release: REQUIRED by ALL Student Team Members, Advisors, Chaperones, and Guests attending the 2026 NCF-Envirothon Mississippi Competition.

Deadline: June 5, 2026 ¹

Please Note:
- • Proof of Medical Insurance is Required ² - An electronic copy (picture or scan) of the attendees Medical Insurance information (card) should be uploaded to this form (follow the directions below) ³. Please have a scan or photo of the front and back of the medical insurance card available in order to proceed.
¹ Advisors/Chaperones and Guests from Maine, Ohio, and Maryland have 7 days from the conclusion of their state/provincial Envirothon competition to complete all Required Registration Forms:
a. Maine - due on June 9
b. Ohio - due on June 12
c. Maryland - due on June 22

² For individuals not currently covered under any health insurance plan, a temporary limited policy (such as 'travel medical insurance', can be obtained to cover the timeframe of the competition. A minimum of 7-14 days is recommended to cover all travel to and from the event location as well as the 6-days of the competition itself.

³ Uploaded copies of Insurance information, will be deleted upon conclusion of competition.
State/Province/Partner Nation of Registered Attendee:
Name of Registered Attendee: Name of Registered Attendee: * First Last
Registered Attendee's Email *
Attendee is registered as a: *

Attendee is registered as a: Team Advisor/Chaperone Guest (including Operating Committee Members, CAT members, State/Provincial Reps, and volunteers)
Attendee's Address Attendee's Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Attendee's Date of Birth Attendee's Date of Birth * / MM / DD YYYY
Is the attendee currently 21 years of age or older? *

Is the attendee currently 21 years of age or older? Yes No
Reminder:

• All Guests, Advisors, and Chaperones must be 21 year of age or older in order to attend the NCF-Envirothon Annual Competition.
Emergency Contact Information

-> Spouse, relative, or other that will be contacted in the case of a medical emergency.
Name Name * First Last
Cell Phone Cell Phone * - ### - ### ####
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Email
Relationship to Attendee *
Additional Emergency Contact(s): Please provide name, contact #s, and relationship status to participant (Optional)
MEDICAL INFORMATION
Gender of Attendee *

Gender of Attendee Male Female Self Describe Self Describe

Please select any health concerns which may recur during the event or be a factor in any medical treatment: *
	Yes	No
Asthma	AsthmaYes	AsthmaNo
Diabetes	DiabetesYes	DiabetesNo
Food-based Allergy	Food-based AllergyYes	Food-based AllergyNo
Medication-based Allergy	Medication-based AllergyYes	Medication-based AllergyNo
Allergy to latex	Allergy to latexYes	Allergy to latexNo
Physical Disability	Physical DisabilityYes	Physical DisabilityNo
Epilepsy or other seizure condition	Epilepsy or other seizure conditionYes	Epilepsy or other seizure conditionNo
Other	OtherYes	OtherNo

If you selected 'Other', please list below:
Food-Based Allergies

Please list all food-based allergies (eggs, dairy, fish, shellfish, wheat, soy, gluten, sesame, etc.) *
Medication-Based Allergies

Please list all medication-based allergies (antibiotics, sulfa drugs, aspirin, etc.) *
Other Allergies

Please list any other allergies we should be aware of in the event of an emergency (severe reactions to insect bites and stings, animal dander, latex, etc.)
Special Accommodations

If you have a disability or special need and may require accommodations in order to fully participate or be treated in case of emergency, please indicate below: *
Medications

Please list all Medications you are taking that medical personal should be aware of in the event of an emergency *
Physician/Medical Provider Information
Physician's name and/or name of Medical Practice where your medical history is kept: *
Physician's Phone Number Physician's Phone Number * - ### - ### ####
INSURANCE INFORMATION - REQUIRED

Per the NCF-Envirothon Annual Competition Rules and Regulations, each individual in attendance must provide proof of health insurance.
- • Please make sure you have an electronic copy of the front and back of the individual's medical insurance card to complete this form.
-> For individuals not currently covered under any health insurance plan, a temporary limited policy (such as 'travel medical insurance') can be obtained to cover the timeframe of the competition. A minimum of 7-14 days is recommended to cover all travel to and from the event location as well as the 6-days of the competition itself.
Name of Insurance Company *
Insurance Company Phone Insurance Company Phone * - ### - ### ####
Primary Card Holder Name on Insurance Policy
(self/spouse) Primary Card Holder Name on Insurance Policy
(self/spouse) * First Middle Last
Primary Card Holder Email *
Proof of Insurance - Card Upload
- PDF, JPG, TIF, PNG or GIF are preferred file formats.
Front of Insurance Card (or Proof of Insurance documentation)

Attach Files
Back of Insurance Card

Attach Files
MEDICAL and INSURANCE INFORMATION CONFIRMATION
Registered Attendee's Approval *

Registered Attendee's Approval I certify that all information provided is correct
Signature: Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Thank you.

2026 Medical and Insurance Information: Adults

2026 Medical and Insurance Information: Adults

Reminder:

• All Guests, Advisors, and Chaperones must be 21 year of age or older in order to attend the NCF-Envirothon Annual Competition.

Emergency Contact Information

-> Spouse, relative, or other that will be contacted in the case of a medical emergency.

MEDICAL INFORMATION

Physician/Medical Provider Information

Proof of Insurance - Card Upload

PDF, JPG, TIF, PNG or GIF are preferred file formats.

MEDICAL and INSURANCE INFORMATION CONFIRMATION

Thank you.

2026 Medical and Insurance Information: Adults

2026 Medical and Insurance Information: Adults

Reminder: • All Guests, Advisors, and Chaperones must be 21 year of age or older in order to attend the NCF-Envirothon Annual Competition.

Emergency Contact Information -> Spouse, relative, or other that will be contacted in the case of a medical emergency.

MEDICAL INFORMATION

Physician/Medical Provider Information

Proof of Insurance - Card Upload PDF, JPG, TIF, PNG or GIF are preferred file formats.

MEDICAL and INSURANCE INFORMATION CONFIRMATION

Thank you.

Reminder:

• All Guests, Advisors, and Chaperones must be 21 year of age or older in order to attend the NCF-Envirothon Annual Competition.

Emergency Contact Information

-> Spouse, relative, or other that will be contacted in the case of a medical emergency.

Proof of Insurance - Card Upload

PDF, JPG, TIF, PNG or GIF are preferred file formats.