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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 *

// (mm/dd/yyyy)

Emergency Contacts

Please provide full and accurate information for every field

Do you have a primary care physician? *

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? *

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.)? *

Do you have any specific mobility issues (ie. use a cane, walker, wheelchair, etc.)? *

If you do have difficulty walking and/or have specific mobility issues, Please explain:

Do you have any significant health problems? *

If "Yes," please explain:

Have you been hospitalized or had any surgery during the last five years? *

If "Yes," Please list:

Please indicate past or present illnesses or conditions: *

Allergies
Hepatitis
Paralysis
Amoebic dysentery
Heart Condition (heart failure, coronary artery disease, cardiomyopathy, pacemaker)
Hypertension
Pneumonia
Asthma
Hypoglycemia
Rheumatic fever
Diabetes
Infectious mononucleosisTuberculosis
Epilepsy
Kidney trouble
Ulcers
Foot/leg difficulties
Pregnancy
Gastro-intestinal difficulties
Malaria
Heart difficulties
Migraine headaches
Cancer
Chronic Obstructive Pulmonary Disease (COPD)
Sickle Cell disease
Other

If "Other," please explain:

Do you have any life threatening allergies (ie. peanuts, shellfish, insects, medications, etc.)? *

If "Yes," Please list what they are:

Do you carry an EpiPen? *

Do you have any dietary restrictions that you would like us to know about for meal planning? *

If "Yes," please list and describe what they are:

Will you need to dispose of needles or other sharp medical devices? *

Do you use a CPAP machine for sleep apnea? *

Are you currently taking or will be taking any medication (Including over-the-counter medications) during the trip? *

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.

By checking the box you agree and confirm that to the best of your knowledge, the above information is complete, true and correct. *

Agree

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NCGE Around the World - Health & Safety, and Emergency Contact Form

Emergency Contacts

General Health

Welcome!