Medical Form
Name: ……………………………………………………………………………………………………………......
ID Number: …………………………………..... Passport Number: ……………………......
Medical Insurance Details
Name of Medical Insurance: ………………………………………………………………………......
Medical Insurance Number: ……………………………………………………………......
Medical Insurance Contact Person and Details: ……………………………......
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Does this include a hospital and evacuation plan? Yes No
Briefly explain your benefits: ……………………………………………………………......
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Please note that if you do not have Medical Insurance, you need to get travel insurance for the duration of your trip to Western Zambia, or you must give proof of sufficient finances in case of an emergency.
Emergency Contact Details
Contact person in case of emergency: ……….………….……………………………………......
Relationship: ………………………………………………………….………………………………………......
E-mail Address: ………………………………………………………….…………………………………......
Contact Number(s): ………………………………………………………….…………………………......
Address: …………………………..………………………………………………….………………………......
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Medical information
Name of Malaria Prophylactic to be used? ……………………………......
(This is compulsory, unless you have a medical letter)
Have you ever contracted Malaria before? Yes No
If yes, please provide us with how and where it was contracted and what treatment you received.
………………………………......
What is your Blood Type?
Do you have any of the following: / Yes / NoAllergies
Asthma
Stomach Problems
Rheumatic Fever
Heart Condition
Epilepsy
Diabetes
Eyes, Ears, Nose, Throat problems
Chronic Back Problems
Depression
Any history of mental illness
If you answered ‘yes’ to any of the above or have other medical conditions not listed, please give a brief description of medical history:
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South Africans and those traveling via South Africa need to be enaculated against ‘Yellow Fever’. No additional enaculations are required, but you can check with your countries requirements.
Please attach any relevant medical documents & letters to this form.
I hereby declare that to my knowledge, the information provided is accurate and true. I also understand that the Zambia Project, Worldwide Missions, the sending church/organization, the staff of the Zambia Project and the volunteer leaders are in no way liable in respect to any personal illness or injury that may occur to myself during my involvement with the Zambia Project.
I also hereby authorize the staff and volunteer leaders of the Zambia Project WWM to act within their best judgment during any emergency situation where I may require medical attention.
Name in full: …………………………………………………………………………..………………………………………
Signature: ……………………………………………………………….………………………………………………………
Date:…………………………………………………..… Place: ……………………..…………………………………..
Witness 1: …………………………………………… Witness 2: ……………………………………………………