Health And Wellness Form Health and Wellness Step 1 of 5 20% General InformationTrip*CubaSouth AfricaTurkeyWashington DCPlease select the trip you are filling out the form for.Name* First Middle Last Cell Phone*Home Phone*Email Address* Sex* Female Male Citizenship InformationCountry of Citizenship* Date of Birth* MM slash DD slash YYYY I have a valid passport* Yes No Application Pending If you have a valid passport, complete the following Passport NumberDate Issued MM slash DD slash YYYY Expiration Date MM slash DD slash YYYY Health and Wellness InformationShort term mission trips can be physically and emotionally demanding. Please thoughtfully assess your health in light of the potential rigors of the trip. Examples: Climatic changes--high temperatures (90 - 110 F) and/or high humidity; change in altitude (5000 ft. Johannesburg) • Exposure to unfamiliar bacteria due to change in diet • Long days and intense schedules • High levels of air pollution • Travel in cramped vehicles • Some travel on foot on uneven ground • Limited availability of some medical equipment and medicines in some countries • Significant time difference. These factors, combined with potential strains from culture shock and intensive interaction with other group members, can affect your health. Illnesses requiring bed rest impair one’s ability to participate in scheduled programming, and can affect the entire group’s learning process. We ask that you assess your physical and mental condition carefully and encourage you to consult with your health care provider if needed. The medical information you provide here will not be used to determine your acceptance into the program. We require that you provide us with the following information so that our staff can make any possible accommodations to meet your health needs, and respond to emergencies. Any information you provide will be kept confidential. Feel free to contact Br. Paul O’Keeffe directly if you have any questions. 1. Age* 2. Do you have a history of any of the following medical conditions?* epilepsy allergies (including allergies to any medicine--list them below) heart condition arthritis (or other condition that limits mobility-list below) asthma diabetes back problems or other injuries emphysema high blood pressure alcoholism (past or present) eating disorders other substance abuse or chemical dependancies any other medical conditions (list below) List Allergies and/or Other Medical Conditions here:How might any of these conditions effect your travel? 3. Are you currently or have you been under a doctor's care during the past six months?* Yes No If yes, what condition(s) are being treated? Also, how might these effect your travel?4. Please indicate if you have been treated by a psychaitrist, psychoanalyst or therapist for any mental, emotional or nervous disorder?* Yes No If yes, how might this affect your travels?5. Mission trips are very intensive, emotionally and physically. Have you had any traumas or life changes in the last six months (death of a loved one, sexual assault, divorce, physical or emotional illnesses, etc.)* Yes No Do you have any limitations in walking or climbing stairs that might affect your participation?* Yes No Do you carry any medication?* Yes No If you answered yes please specify names of the medications, conditions they treat, possible side effects, and frequency that you take them:7. Are you currently on any special diet (even if voluntary, such as vegetarian)?* Yes No If yes, please provide relevant details 8. Is there anything else you would like us to be aware of concerning your physical or mental health?* Yes No Emergency Contact InformationWho should we contact in case of an emergency?* First Last What is your relationship to your emergency contact?* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone (day)*Phone (evening)* Health & Wellness CertificationI understand and agree that Br. Paul O’Keeffe and/or a chaperone may notify the person or persons that I have listed as emergency contacts in the event that I become ill, injured, or involved in an emergency situation during the trip, and that such information may be disclosed to health care providers and emergency workers if I need medical care during the duration of my stay in South Africa. In the event that I am unable to make my own medical decisions, Br. Paul and/or chaperones may have to make those on my behalf. I HAVE CAREFULLY READ THE ABOVE TERMS AND CERTIFY MY ACCEPTANCE OF THESE CONDITIONS* Yes No CertificationBy typing my name in the boxes below, I agree that the above information is correct to the best of my knowledge and I consent to the conditions and policies stated above. I agree that I will assume all medical costs incurred while participating on this mission trip that are not covered under my travel insurance. Name* First Last Date MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. Δ
