Global Team Application Name * First Name Last Name Email * Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Which trip are you interested in? * Philippines: June 1st - June 11th Gender * Male Female Medical History Emergency Contact * First Name Last Name Emergency Contact's Phone Number * (###) ### #### Relationship to you * Primary Care Physician's Name and Phone Number * My current state of health is..... * Excellent Good Fair Poor My regular fitness level is....... * Very fit Moderately fit Fit Not fit Do you have any physical limitations or disabilities that would affect you in less than ideal situations such as extreme heat or cold, limited food choices, or in an emergency situation? Do you now or have you ever had... * Diabetes Seizures Fainting Spells Epilepsy Eating Disorder Respiratory Problems Psychiatric Care Medication for Depression Medication for Behavior Other None of the above If other, please explain Are you currently taking any medication for a medical condition? * Please list any allergies Date of last tetanus shot? * Any other information we need to know? Thank you!
