2018 Guatemala Trip Medical Info Form

The below Medical Form will be needed for all those wishing to join the Mission Trip to Guatemala June xxxx – zzzz,.2018

Participant Information
Name ______________________________________

Phone # __________________________________

Address ___________________________________________________________________
Spouse _____________________________________

Phone # ____________________________________

Insurance / Medical Information
Insurance ___________________________________

ID # _______________________________________
Group # ____________________________________

Phone _____________________________________
Doctor _____________________________________

Phone # ___________________________________

Address ___________________________________________________________________

Known Allergies _______________________________________________________________________________________________________________________________________________

Physical Limitations __________________________________________________________

Known Medical Conditions ______________________________________________________
______________________________________________________________________________________________________________________________________________________

*** It is the participant’s responsibility to verify that he or she is physically and emotionally able to participate in the 2017 Guatemala Trip,  and therefore, immunizations must be current on this Medical Form.

Medical Form Emergency Contacts (please provide three)
Name _______________________________________________

Phone # _________________________
Address  __________________________________________________________________

Name _______________________________________________

Phone # _________________________

Address ___________________________________________________________________

Name _______________________________________________

Phone # _________________________

Address ___________________________________________________________________

Necessary Documents for Guatemala Trip 2017
PLEASE PROVIDE COPIES OF ALL DOCUMENTS

* Driver License or State Issued ID # ___________________________________

State _______________

Legal name on DL or ID _______________________________________________________

* Passport # ________________________________________________________________

* Please include copies of above mentioned insurance card

* Please include copies of immunization records

According to the United States Center for Disease Control, Americans traveling to Guatemala should ensure routine vaccines are up to date at least 4-6 weeks before traveling. These include; Measles-Mumps-Rubella (MMR), Diphtheria-Tetanus-Pertussis, Varicella (Chickenpox), and Polio Vaccines, as well as the yearly flu shot.

In addition, the CDC also suggests that most travelers also get vaccinated for Hepatitis A and Typhoid.

They further suggest that some, but not all, travelers get immunized for; Hepatitis B, Malaria, Rabies, and Yellow Fever.

Local Health Departments usually carry these immunizations, but you may want to call in advance.

http://wwwnc.cdc.gov/travel/destinations/traveler/none/guatemala

 

 

2017 Guatemala Trip Medical Info Form