2020 MTW Health Form

  Participant Information

*

Name:

 

 

   

*

*

 

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


*


*  


*  


*  


  Please provide your health insurance carrier information in the boxes below. If you do not have a health insurance carrier, please indicate by typing N/A in these boxes. Staff will be in touch if health insurance information is not provided.
*  


*  


*

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

*

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

 

Emergency Contact 

*  


*  


*  


*  


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

 

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

 

  Medications for Psychosocial Conditions
 

  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
 

  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
*

 

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. Also, 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. Also, while we will make reasonable efforts to assure that dietary needs are honored, please understand that we are not able to control the contents of food products during travel or during the Operation Smile Mission Training Workshop. 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.

 

Please note: the health information is collected to be used in case of medical emergency and to the extent appropriate, to accommodate individual needs of Operation Smile – Mission Training Workshop 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. 

*


 
   Please leave this field empty