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)

Age *

Sex *

MALE

FEMALE

Address *

(City, Prov., Country)

Your Phone Number *

Your Email Address *

Pastor/Group Leader Full Name *

Church Name *

EMERGENCY CONTACT INFORMATION

Emergency Contact Information *

(Full Name, Phone Number, Email, Relationship to You)

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.

YES

Required

If you answered "NO" above, please list in the space below the travel documents that you have:

(i.e. passports, residency, etc.)

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).

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)

Do You Have Allergies? *

YES

If You Responded YES to Allergies above, please describe below.

(Type of allergy, medication being taken currently)

Are You Taking Any Medications? *

(prescribed or otherwise)

YES

If You Responded YES to Medications above, please describe below.

(Name of medication, dosage, condition taken for)

What is the Date of Your Last Tetanus Shot? *

(dd/mm/yyyy)

Do you have any limiting disabilities or physical handicaps? *

YES

If You Responded YES to Disabilities above, please describe below.

Have you had any major illnesses in the last five years? *

YES

If you answered YES to Major Illnesses above, please describe below.

(Name of illnesses, treatment/surgery performed, duration of illness, etc.)

Are you currently under the doctor's care or have you been under a doctor's care in the past year? *

YES

If you answered YES to Doctor's Care above, please explain below.

(Illness, treatment, medications, frequency of checkups, etc.)

If you have any other medical conditions or disabilities we should be aware of, please describe in detail below:

Is there anything else we should know before you come? Please tell us.

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