Franciscan Missionary Union

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Health And Wellness Form

Health and Wellness

Step 1 of 5

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  • General Information

  • Please select the trip you are filling out the form for.
  • Citizenship Information

  • MM slash DD slash YYYY
  • Passport Number
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Health and Wellness Information

    Short 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.
  • Emergency Contact Information

  • Health & Wellness Certification

    I 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.
  • Certification

    By 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.
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

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