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Confidential Health Form – Aswan 2019

Confidential Health Form for Alliance for Smiles mission to Aswan, Egypt – November 2 to 15, 2019

Volunteers with known and ongoing medical problems, such as allergies or diabetes, must take special precautions in preparing for and managing their situation. You need to anticipate how your new environment and the stresses of a mission in a foreign country can impact your health. There may be fewer resources in foreign settings to help you deal with health problems. For example, a volunteer with allergies needs to ensure that specialized medications will be available, and someone with diabetic needs to consider the consequences of contracting malaria.

Volunteers Using Medication: If you use medication on a regular basis, you should take a supply to last throughout your stay and carry a letter from your physician explaining the medical necessity and treatment.

Travel Insurance: Alliance for Smiles (or Rotary International) provides travel medical insurance for all team members. All team members must be covered under this insurance policy, regardless of whether you have your own insurance policy.

EMERGENCY CONTACT # 1:

EMERGENCY CONTACT # 2:

By clicking SUBMIT, I certify that all of the above information is accurate, true and complete to the best of my knowledge. I also consent to any necessary examination, anesthetic, medical diagnosis, surgery, treatment and/or hospital care rendered to me under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine by the state or country in which they practice, during the duration of the trip identified above.