Operation Smile - Survey - ISLC 2023 HEALTH INFORMATION

ISLC 2023 will be held at El Pueblo Resort from July 17-23, 2023.

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 2023 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

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. Staff will 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 - Travel insurance policy name:

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

Question - Not Required - Does your travel insurance policy include COVID insurance?

Question - Not Required - Did you purchase COVID supplemental insurance?

Question - Not Required - If yes: Name of COVID supplemental insurance?

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

What is covered by your COVID supplemental insurance policy?

(Select one of the available choices or enter a different value.)
Question - Not Required -

Medical Information

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Question - Required - Please check the boxes below if the participant has any of the following psychosocial conditions or symptoms:

	Anxiety
	Asperger's syndrome
	Depression
	Panic Attacks
	ADHD
	Phobias
	Other psychosocial health concerns
	None of the above

Question - Not Required - If any boxes are checked above, please explain below:

List any medications the participant will use during the conference. If there are no medications, please state none in the box below.

Question - Not Required - Medications for Medical Conditions:

Question - Not Required - If any of the boxes are checked above, please explain using the space below:

Medications for Psychosocial Conditions

Question - Not Required - List any medications the participant will use during the conference.

List any known allergies, including specific medicines, foods, bites, and stings as well as the reaction and medication required for treatment. If no allergies are known, please state none in the box below.
Allergies

Question - Not Required - Include specific medicines, foods, bites, and stings as well as the reaction and medication required for treatment.

Please list all dietary requirements, if there are no special requirements please list none in the box below. We will endeavor to accommodate meal requests in advance; however, not all requirements can be met.
Dietary Requirements

Question - Not Required - We will endeavor to accommodate meal requests provided in advance; however, not all requirements can be met.

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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:

Question - Not Required - Name:

Question - Not Required - Relationship:

Question - Not Required - Phone:

Question - Not Required - Email:

Question - Not Required - Language spoken:

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

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.

Because this conference takes place in Peru, some additional steps may be required to travel with your medications. Some medications may be considered controlled substances, and may not be ready for travel. Please confirm with your Peruvian consulate what medications may require additional paperwork. Please note that you may need a letter from your prescribing physician for your medications, particularly injectable medications, for international travel. Participants are responsible for ensuring medications are able to pass through Peruvian customs upon arrival. Additionally, it may be advisable to bring a prescription for a generic refill of medication, should it be needed in an emergency in Peru.

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 2023. 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 the conference.