Confidential Health Form – Gazipur, Bangladesh 2024

    Confidential Health Form for Alliance for Smiles mission to Gazipur, Bangladesh from February 12 to 23, 2024

    COVID-19

    AfS requires all volunteers to be vaccinated against COVID-19. You are considered fully vaccinated against COVID-19 two weeks (14 days) after your dose of an accepted single-dose vaccine or two weeks (14 days) after your second dose of an accepted 2-dose series.

    Covid Vaccine:

     

    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.