Medical Information

This information will be held confidential between the participant, team leader, RN on the ground in Israel, and any necessary medical professional in the event of an emergency.

    *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.?

    If yes, please explain

    List all current medications and purpose:

    *Are you pregnant?

    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: