Emergency Info

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Medical / Contact Information

	Please provide complete and accurate information! To complete the form below you may want to gather the following information: Blood Type Medical History All Prescription Medications to be Taken During the Trip Personal Physician Contact Info Known Allergies Name and Info for 3 Emergency Contacts Fields marked with an *()** are required to submit the form.
	Medical Information
FIRST Name (*)	Invalid Input	Your FIRST NAME only.
LAST Name (*)	Invalid Input	Your LAST NAME only please.
Gender (*)	MaleFemale Invalid Input
Date of Birth (*)	Invalid Input	Please enter or select your date of birth.
Family Physician (*)	Invalid Input	Please list the name of your family physician. If none, please type "NONE".
Phone Number (*)	Invalid Input	Please insert your physician's contact phone number(s). Preferably one that is answered 24 hours a day. If none, please enter "NONE".
Blood Type (*)	Invalid Input	Please enter your blood type.
Select all childhood diseases with which you were physician diagnosed. (*)	MeaslesMumpsRubellaChickenpoxRheumatic FeverNONE Invalid Input	Please select any conditions in your medical history. If none, be sure to select "NONE".
Medical History	Invalid Input	Please list any serious medical conditions for which you have been diagnosed by a physician. If none, please enter "NONE".
Surgical History	Invalid Input	Please list any surgical procedures you've undergone.
Alergies	Invalid Input	Please list ALL known allergies; Foods Medicines Plants or Insects Other Allergies
Prescription Drugs (*)	Invalid Input	Please list all prescription drugs you will be have in your possession at any time during the trip. Include inhalers, injectors, antibiotics, etc. If none, please enter "NONE".

	Emergency Contact Information
Name - Contact 1 (*)	Invalid Input	Contact FIRST and LAST Names
Relationship	Invalid Input	Please define your relationship to this contact. Ex. Father, Mother, Spouse, Friend, etc.
Cell Phone (*)	Invalid Input	Please enter a cellphone number if available. If none, please enter "NONE".
Home Phone (*)	Invalid Input	Please enter a home phone number if available. If none, please enter "NONE".
Work Phone (*)	Invalid Input	Please enter a work phone number if available. If none, please enter "NONE".
Email Address (*)	Invalid Input	Please enter an email address for this contact. If none, please enter "NONE".
Name - Contact 2 (*)	Invalid Input	Contact FIRST and LAST Names
Relationship	Invalid Input	Please define your relationship to this contact. Ex. Father, Mother, Spouse, Friend, etc.
Cell Phone (*)	Invalid Input	Please enter a cellphone number if available. If none, please enter "NONE".
Home Phone (*)	Invalid Input	Please enter a home phone number if available. If none, please enter "NONE".
Work Phone (*)	Invalid Input	Please enter a work phone number if available. If none, please enter "NONE".
Email Address (*)	Invalid Input	Please enter an email address for this contact. If none, please enter "NONE".
Contact 3 (*)	Invalid Input	Contact FIRST and LAST Names
Relationship	Invalid Input	Please define your relationship to this contact. Ex. Father, Mother, Spouse, Friend, etc.
Cell Phone (*)	Invalid Input	Please enter a cellphone number if available. If none, please enter "NONE".
Home Phone (*)	Invalid Input	Please enter a home phone number if available. If none, please enter "NONE".
Work Phone (*)	Invalid Input	Please enter a work phone number if available. If none, please enter "NONE".
Email Address (*)	Invalid Input	Please enter an email address for this contact. If none, please enter "NONE".

Affirmation Signature	Invalid Input	By entering your name, you affirm that all of the above answers are, to the best of your knowledge, complete, truthful, and accurate. Please enter your FIRST, MIDDLE, and LAST names.
Let's make sure your human!	Invalid Input	This field prevents spammers and other malcontents from abusing the site. Since most spammers are overseas, a short term trip is a good way to strike a blow against SPAM!
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