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Medical Information

Your Name EXACTLY as on the passport:

Title

First Name:

Last Name:

Middle/Maiden Name

Birthdate

Gender:

MaleFemale

Individual to Contact in an Emergency

Title

First Name:

Last Name:

Relationship to you:

Email Address:

Primary Phone Number:

Include country code if outside the USA

Phone type

CellHomeWork

City / Town of emergency contact:

State / Province of emergency contact:

Blood Type and Is there anything else the team leaders should know concerning your health & medical history or needs?:

Any food or drug allergies and your reaction to and severity of these allergies:

All prescription medicines you are presently taking (including generic names) and the strength/dosage of each:

Anything else the team leaders should know concerning your health & medical history or needs

Please indicate your physical stamina:

ActiveLess EnergeticEasily Fatigued

Name of Physician to Contact in an Emergency

Physician's Phone Number

City and State of Physician