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Sites
Trips
Internships
Residency
GiveBack
Alliance Opportunities
Summit
APPLICANT MEDICAL FORM
APPLICANT INFORMATION
Name
*
Name
Full legal name
First Name
Last Name
Date of Birth
*
Date of Birth
MM
DD
YYYY
Gender
*
Male
Female
Location of Service
*
Atlanta
Bangkok
Burkina Faso
Chicago
Cleveland
Colombia
Dominican Republic
Eastern Europe
Ecuador
El Salvador
Guinea
Indonesia
Mali
Mexico
Miami
Paris
Peru
Philippines
Providence
Spain
Taipei
*Other
MEDICAL INFORMATION
Medication Allergies
Please list any allergies you have to medications
Dietary Restrictions
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?
*
Yes
No
If so, what?
Have you ever been treated or hospitalized for a mental or emotional condition?
*
Yes
No
If so, what?
Do you regularly use any prescription medication?
*
Yes
No
If so, what?
Are you willing to receive vaccines if necessary?
*
Yes
No
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.
Primary Insurance Company
*
Insurance Policy Number
*
Insurance Policy Expiration Date
*
Insurance Policy Expiration Date
MM
DD
YYYY
EMERGENCY CONTACTS
Primary Contact Name
Primary Contact Name
First Name
Last Name
Cell Number
*
Cell Number
(###)
###
####
Relationship to You
*
Secondary Contact Name
*
Secondary Contact Name
First Name
Last Name
Cell Number
*
Cell Number
(###)
###
####
Relationship to You
*
IMMUNIZATIONS
Hepatitis B
MM/DD/YY
Polio
MM/DD/YY
Tetanus
MM/DD/YY
MMR
MM/DD/YY
Chicken pox disease
MM/DD/YY
Chicken pox vaccine
MM/DD/YY
Tuberculosis skin testing (if known)
MM/DD/YY
PPD
Thank you for completing your medical form!