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Confidential Health Information
Yayasan ASRI has been hosting visitors since 2007, and in order to maintain this strong track record, we commit to providing thorough information about health and safety issues (focusing on prevention) and clear expectations about engaging with our programs and communities. We ask that you, too, provide clear, thorough information to ensure that your trip can be a safe, rewarding experience. We will use this information only as it is relevant to planning your trip and in case of emergency, and it will be kept confidential in a secure database.
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Email *
First name *
Last name  *
Health Information 
Please fill in all information clearly and completely. Keep in mind that we gather this health information so that ASRI staff are adequately prepared to respond should you require medical attention. This information is otherwise kept confidential.
Primary health insurance provider name and ID/group number
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Do you have any past or present medical conditions? Please include relevant details on date of last occurrence, symptoms, treatment plan, and restrictions to program activities.
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Do you have any allergies? Include allergies to medicine, foods, insect bites/stings, environmental, etc. Please describe severity and reactions to each item listed. If none, please say N/A
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Please indicate any dietary restrictions
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Please list any medications you are currently taking *
Please provide an overall summary of your present physical and mental health.
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Emergency contact *
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