APPLICANT MEDICAL FORM

APPLICANT INFORMATION

Name *

Name

Full legal name

First Name

Last Name

Date of Birth *

Date of Birth

YYYY

Gender *

Male

Female

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

If so, what?

Have you ever been treated or hospitalized for a mental or emotional condition? *

Yes

If so, what?

Do you regularly use any prescription medication? *

Yes

If so, what?

Are you willing to receive vaccines if necessary? *

Yes

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

YYYY

EMERGENCY CONTACTS

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