M2: Short-Term Missions Medical Online Form

M2: Short-Term Missions Medical Online Form

This form is a combination of medical factors such as medications and/or allergies LHI should be aware of to ensure a safe and healthy visit, as well as the appropriate course of action if medical attention is needed.
Name *

First Name Last Name
Birthdate *

Month Day Year
Team/Group Name *
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Emergency Contact
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Health Insurance Information
Company *
Name on Policy *
Policy Number *
Will this cover any medical expenses in Mexico? *

Yes No
Health Information

Please list all of the medications you are currently taking (including vitamins, birth control, etc...) *

Medication

Dosage

Frequency

Duration

Please list all allergies and what kind of reactions you have *

Allergy

Reaction

Treatment

Please list any medical conditions *

Condition

Past/Present

Blood Type *
Not sure? Enter: Note sure
Have you been (or will you be) in contact with anyone who has traveled to mainland China within 15 days of your planned visit to Esperanza Viva?

Yes No
Have you traveled (or will you be traveling) outside of the United States within 15 days of your planned visit to Esperanza Viva? *

Yes No
Please review the following link for the Center for disease and Controls recommendation on Vaccines when traveling to Mexico: https://wwwnc.cdc.gov/travel/destinations/traveler/none/mexico

Living Hope International reserves the right to cancel or postpone any current or upcoming Short-Term Missions team member visit per our discretion without being held responsible or liable for any present or future compensation or charges that may incur as a result of this. Furthermore, we reserve the right to close our campus entrance to anyone showing severe health symptoms that were not previously reported. By submitting this form you agree to all the terms listed above and agree to report any health conditions or symptoms prior to your arrival at the Esperanza Viva campus.
Please notify LHI of any illness symptoms that develop before you arrive (such as cough, sore throat, etc.). If you have further health-related questions please email: Clinica@LoveHopeMercy.org
Comments:
The information above is true and I agree and understand the terms and conditions. *

Yes
Should be Empty:

Emergency Contact