Operation Smile - Survey - ISLC 2024 Health Form

ISLC 2024 will be held at Emory University in Atlanta, Georgia, USA from July 22-28, 2024.

All participants are required to complete the following health information. Participants under the age of 18 need a parent/guardian to complete this form.

Health information is collected to be used in case of medical emergency and to the extent appropriate, to accommodate individual needs of Operation Smile ISLC 2024 participants. All information is treated as confidential and will be released to Operation Smile leaders and/or staff. In the event of an emergency, information provided will be given to the appropriate medical authority.

For any questions regarding this health form, medical conditions, dietary requirements, etc. please email ISLC@operationsmile.org.

Participant Information

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Name:

First Required	Last Required

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Email: Required

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Phone Number: Required

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Date of Birth: Required

Date of Birth:

If you respond and have not already registered, you will receive periodic updates and communications from Operation Smile.

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Question - Required - Age:

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Question - Required - Height (in feet & inches):

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Question - Required - Weight (in pounds):

Insurance Information

Please provide your health insurance information in the boxes below. If you do not have a health insurance policy, please indicate by typing N/A in these boxes. Operation Staff may be in touch if health insurance information is not provided. It is a requirement to have health insurance coverage for this conference, and staff may be able to share information regarding any supplemental insurance questions you may have for international travel.

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Question - Required - Health Insurance Company:

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Subscriber (registered member of the health insurance):

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Policy Number:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Group Number:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - If applicable, travel insurance policy name:

(Maximum response 255 chars, approx. 5 rows of text)

Medical History

Question - Not Required - If applicable, please list any known allergies (including specific foods, medicines, bites, and stings) as well as the reaction and medication required for treatment below.

Question - Not Required - If applicable, please list all dietary requirements below. We will endeavor to accommodate meal requests in advance; however, not all requirements can be met.

	Celiac/Gluten Free
	Kosher
	Lactose Intolerant/Dairy Free
	Pescatarian
	Vegetarian
	Vegan
	Other

Question - Not Required - If applicable, please list any perscribed medication and describe reasoning that will be used during the conference:

Question - Not Required - Please check the box(es) below for any psychosocial conditions or symptoms:

	Anxiety
	Depression
	Panic Attacks
	ADHD
	Phobias
	Other

Question - Not Required - If you checked any box(es) above for psychosocial conditions or symptoms, please explain:

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Question - Required - Have you been vaccinated for COVID-19?

Question - Not Required - What vaccine(s) did you receive?

	Pfizer-BioNTech
	Oxford-AstraZeneca
	Sinopharm BIBP
	Moderna
	Johnson and Johnson Janssen
	CoronaVac
	Covaxin
	Novavax
	Medicago

Question - Not Required - Date(s) of your COVID-19 vaccination(s):

Medical Emergency Contact

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Question - Required - First and Last Name:

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Question - Required - Relationship to Participant:

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Question - Required - Phone Number:

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Question - Required - Email Address:

Question - Not Required - Language spoken:

(Maximum response 255 chars, approx. 5 rows of text)

Please email a copy of your insurance card to ISLC@OperationSmile.org with the subject line: First Name, Last Name - Insurance

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Question - Required - I have emailed a copy of my insurance card to ISLC@OperationSmile.org

Terms and Conditions

Note: If you believe OSI should receive additional information regarding any conditions you noted above or other circumstances, please provide such information in writing when you submit this form.

Participants must bring any medicine they will need during the conference in a labeled container in carry-on luggage. We require all participants of Operation Smile events to care for their recurring medical treatments without supervision.

All medications, injections or other treatments must be monitored and administered solely by the participant.

We will make reasonable efforts to assure that dietary needs are honored, but please understand that we are not able to control the contents of food products during travel or during ISLC 2024. Should a participant have strict dietary needs, he/she is ultimately responsible for inspecting all food ingredients related to a specific dietary requirement.

Participants aged 18 or over: I am over the age of 18 and in consideration of being permitted by OSI to participate in Operation Smile events hereby agree to reimburse OSI for all expenses incurred on my behalf by OSI in connection with treatment of me for any medical illness or injury.

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Question - Required - I agree to the terms and conditions of ISLC 2024.