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NCGE Around the World - Health & Safety, and Emergency Contact Form
Participant safety is our top priority and our programs are designed with this in mind. NCGE, however, recognizes that unforeseen emergencies can arise while we are on the trip. In order for our team leaders to best help in the event of an emergency, we ask that you complete a medical report in full, honestly and accurately, and disclose all medical history and information required for your participation. Should your medical situation change after submitting the medical report, it is your responsibility to advise us immediately. All information contained in this report will be kept confidential and held securely on file until 60 days post trip and at such time your information will be securely deleted and/or shredded
First Name *
Middle Name *
Last Name *
Email *
Birth Date *
Emergency Contacts
Please provide full and accurate information for every field
Do you have a primary care physician? *
Yes
No
If "Yes," please provide their information below:
Name of physician:
Physician's phone number:
EMERGENCY CONTACT 1
Contact 1 Full Name: *
Contact 1 Relationship: *
Contact 1 Phone Number: *
Contact 1 Email: *
EMERGENCY CONTACT 2
Contact 2 Full Name: *
Contact 2 Relationship: *
Contact 2 Phone: *
Contact 2 Email: *
General Health
Are you in good health? *
Yes, I am in good health
No, I am not in good health
If "not in good health," please explain:
Will you have any difficulty walking (ie., uneven terrain, using stairs, walking in inclement weather, walking for more than 1 mile, etc.)? *
No
Yes
Do you have any specific mobility issues (ie. use a cane, walker, wheelchair, etc.)? *
No
Yes
If you do have difficulty walking and/or have specific mobility issues, Please explain:
Do you have any significant health problems? *
No
Yes
If "Yes," please explain:
Have you been hospitalized or had any surgery during the last five years? *
No
Yes
If "Other," please explain:
Do you have any life threatening allergies (ie. peanuts, shellfish, insects, medications, etc.)? *
No
Yes
If "Yes," Please list what they are:
Do you carry an EpiPen? *
No
Yes
Do you have any dietary restrictions that you would like us to know about for meal planning? *
No
Yes
If "Yes," please list and describe what they are:
Will you need to dispose of needles or other sharp medical devices? *
No
Yes
Do you use a CPAP machine for sleep apnea? *
No
Yes
Are you currently taking or will be taking any medication (Including over-the-counter medications) during the trip? *
No
Yes
If "Yes," please list all medications and their dosage including over the counter (ie. ibuprofen 200mg twice per day):
Please remember to take with you extra medication in case of an unforeseen prolonged stay during your trip.
