INTERN INFORMATION
Name *
Name
Full legal name
Date of Birth *
Date of Birth
Gender *
Location of Internship *
MEDICAL INFORMATION
Please list any allergies you have to medications
Food allergies, sensitivities, etc.
Do you have any chronic ailment or physical disability that might prevent you from rigorous activities, high altitudes or extreme temperatures? *
Have you ever been treated or hospitalized for a mental or emotional condition? *
Do you regularly use any prescription medication? *
Are you willing to receive vaccines if necessary? *
INSURANCE INFORMATION
Interns must be insured under a US primary coverage policy while on their internship (typically under parents’s coverage if under 26). Envision will also purchase supplemental Emergency/Travel coverage for international interns through Faith Ventures.
Insurance Policy Expiration Date *
Insurance Policy Expiration Date
EMERGENCY CONTACTS
Primary Contact Name
Primary Contact Name
Cell Number *
Cell Number
Secondary Contact Name *
Secondary Contact Name
Cell Number *
Cell Number
IMMUNIZATIONS
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY