Missouri Life Caravan Registration

Registration Deadline is January 2, 2020.

Download the registration form here: Registration Form

Passenger's Name *
Passenger's Name
Address *
Address
Passenger's Date of Birth: *
Passenger's Date of Birth:
Cell Phone
Cell Phone
Land Line Phone
Land Line Phone
Bus Boarding Location *
Have you ridden with us before?
Medical Release *
I do hereby grant permission for medical treatment for this passenger by a licensed medical professional in case of illness or injury during this year's Missouri Life Caravan bus trip to Washington, DC.
Doctor's Name *
Doctor's Name
Doctor's Phone #: *
Doctor's Phone #:
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
For Minor Child: Parent Name
For Minor Child: Parent Name
By printing my name here, I agree that it is intended to be my legal signature for this purpose, that I am the parent, or legal guardian, of the above named minor passenger, and that my permission is granted for the above named minor passenger to travel on the 2020 Missouri Life Caravan buses with me OR in the care of the below signed responsible adult chaperone.
For Minor Child: Parent Phone #
For Minor Child: Parent Phone #
The person listed below has agreed to be the chaperone for my minor child (< 18 yrs old). I give permission for this chaperone (who is 18 yrs or older) to care for this minor. Adults can chaperone a maximum of 4 minors.

***Be sure you clicked the ‘I’m not a robot’ check box above.

Step 2: Checks can be made payable to 'Missouri Life Caravan' and mailed to:

Missouri Life Caravan, 1000 Executive Pkwy, Suite 229, St. Louis, MO 63141