Medical Form for trip

ADULT MEDICAL FORM FOR HAITI MISSION TRIP

This is a confidential form for emergency use only.  It will only be in the possession of the group leader during the trip and will be shredded at the end of the trip.  Please fill it out completely, sign it, and send it to Shantia Wright-Gray, PO Box 7028, Ocean Park, ME 04063

Name                                                                                                                                                                        

Address                                                                                                                                                                   

Date of birth                                                

Emergency contact (someone NOT on the trip)                                                                                           

Emergency contact phone number(s)                                                                                                            

Family Physician name and phone number                                                                                                  

Allergies (please specify)                                                                                                                        

Date of last tetanus shot                          Any other recent shots                                                               

HEALTH CONDITIONS: (check all that apply) Heart__ Asthma__ Other lung problems__ Diabetes__ Seizures__ Stomach problems__ Kidney problems__ Bleeding problems__

High Blood Pressure__ Any other health concerns__

(If you checked any of the above, please attach another page describing your condition, treatments needed, and any other pertinent information about your health condition.)

MEDICATIONS YOU ARE TAKING (OR MAY NEED) List name and dose and number of times

per day that you take them.                                                                                                                                

Health Insurance Information                                                                                                                            

In the case of extreme emergency, I give permission for treatment by a physician.

Signature                                                                                                                  Date