EDMC Health Information Form
Fill out the following form completely and Submit. An EDM Canada representative will review your information prior to your arrival here in the DR.
GENERAL INFORMATION
Full Name *
(First and Last Names)
Your answer
Age *
Your answer
Sex *
Address *
(City, Prov., Country)
Your answer
Your Phone Number *
Your answer
Your Email Address *
Your answer
Pastor/Group Leader Full Name *
Your answer
Church Name *
Your answer
EMERGENCY CONTACT INFORMATION
Emergency Contact Information *
(Full Name, Phone Number, Email, Relationship to You)
Your answer
TRAVEL DOCUMENTATION
Do you have a valid CANADIAN passport? *
If you are not a Canadian citizen, please answer "NO" and explain what documentation you have in the space provided below.
Required
If you answered "NO" above, please list in the space below the travel documents that you have:
(i.e. passports, residency, etc.)
Your answer
What is the expiry date for your Canadian passport (and other travel documents is applicable)? *
Team members cannot participate in Short Term Missions trips with EDMC without a valid Canadian passport (or valid, non-expired Canadian residency card PLUS a valid passport from your country of birth).
Your answer
MEDICAL/HEALTH INFORMATION
MEDICAL INSURANCE *
Valid Travel Medical Insurance is a requirement for participation in Short Term Mission Trips with EDMC (Provider, Policy Number, Expiry Date - Please give copy to Team Leader prior to departure for the DR)
Your answer
Do You Have Allergies? *
If You Responded YES to Allergies above, please describe below.
(Type of allergy, medication being taken currently)
Your answer
Are You Taking Any Medications? *
(prescribed or otherwise)
If You Responded YES to Medications above, please describe below.
(Name of medication, dosage, condition taken for)
Your answer
What is the Date of Your Last Tetanus Shot? *
(dd/mm/yyyy)
Your answer
Do you have any limiting disabilities or physical handicaps? *
If You Responded YES to Disabilities above, please describe below.
Your answer
Have you had any major illnesses in the last five years? *
If you answered YES to Major Illnesses above, please describe below.
(Name of illnesses, treatment/surgery performed, duration of illness, etc.)
Your answer
Are you currently under the doctor's care or have you been under a doctor's care in the past year? *
If you answered YES to Doctor's Care above, please explain below.
(Illness, treatment, medications, frequency of checkups, etc.)
Your answer
If you have any other medical conditions or disabilities we should be aware of, please describe in detail below:
Your answer
Is there anything else we should know before you come? Please tell us.
Your answer
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