Step 2

*Emergency Contact Name

*Emergency Contact Phone

Doctor's Name

Doctor's Phone

Insurance Company Name

Insurance Phone

Insurance Policy #

Are you up to date on travel immunizations? (Tetanus, Typhoid, Hep A&B)

Date of last Tetanus Shot?

*Do you have any health issues?

A hospital / medical practitioner without access to your full medical history may need the following information:

*Do you have any allergies to medicine, food, etc.?
NoYes

If yes, please explain

List all current medications and purpose:

*Are you pregnant?
NoYes

If so, please provide your stage and Obstetrician's name and phone number

List any physical impairments you may have:

*Do you have high or low blood pressure?

List any heart problem you may have

Do you see a cardiologist and if so please list name and date of last visit:

Have you been diagnosed with a psychiatric disorder, if so, name the disorder and medication:

Do you have an immunosuppressive disease or take immunosuppressive meds?

Do you have any other medical problems that we should be made aware of?

I agree that the above information is complete and true, and take full responsibility for my own health while serving in Israel with Cross to Light. I am aware of the risk involved if I choose to go to Israel without medical insurance/s and/or without getting the recommended vaccines and/or medications. I release this information for Cross to Light to share with any medical professional who might require to know about my medical background in order to provide care for me.

*Digital Signature: First Name

*Last Name

If the participant is under 18:
Parent / Legal Guardian Signature:

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