MEDICAL and EMERGENCY INFORMATION
Youth Program Participant
*
First Name
Last Name
Emergency Contacts in USA
Please fill out the contact information for two individuals that we should contact in the USA in case of emergency
USA Contact #1
*
First Name
Last Name
USA Contact #1 Relationship to Youth Program Participant
*
USA Contact #1 Phone Number
*
-
Area Code
Phone Number
USA Contact #1 Email
*
example@example.com
USA Contact #1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
USA Contact #2
*
First Name
Last Name
USA Contact #2 Relationship to Youth Program Participant
*
USA Contact #2 Phone Number
*
-
Area Code
Phone Number
USA Contact #2 Email
*
example@example.com
USA Contact #2 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contacts in India
Please fill out the contact information for one individual that we should contact in India in case of emergency. In case you do not have any contacts in India, we can provide the contact information for the NGO we will be working at.
India Contact #1
*
First Name
Last Name
India Contact #1 Relationship to Youth Program Participant
*
India Contact #1 Phone Number
*
-
Country Code
-
India Contact #1 Email
*
example@example.com
India Contact #1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Pin Code
Back
Next
Travel to India
I have an
*
Indian Visa
Overseas Citizenship of India (OCI)
Indian Passport
Other
Indian Visa Type
Indian Visa Number
Date of Issue (Visa)
-
Month
-
Day
Year
Date
Expiration Date (Visa)
-
Month
-
Day
Year
Date
OCI Number
Date of Issue (OCI)
-
Month
-
Day
Year
Date
Expiration Date (OCI)
-
Month
-
Day
Year
Date
Indian Passport Number
Date of Issue (Passport)
-
Month
-
Day
Year
Date
Expiration Date (Passport)
-
Month
-
Day
Year
Date
Please explain. Include the relevant numbers and dates for your existing document.
Do you have Travel Insurance that will cover your trip to India?
Travel to U.S.
I have a
*
U.S. Passport
U.S. Green Card
Other
U.S. Passport Number
Date of Issue (Passport)
-
Month
-
Day
Year
Date
Expiration Date (Passport)
-
Month
-
Day
Year
Date
U.S. Green Card Number
Date of Issue (Green Card)
-
Month
-
Day
Year
Date
Expiration Date (Green Card)
-
Month
-
Day
Year
Date
Please explain. Include the relevant numbers and dates for your existing document.
Back
Next
Medical Profile and History
Many of the following answers are optional. This information will help us to administer treatment if an emergency arises, but you are entitled to keep your medical information private.
Have you had COVID vaccinations: How many?
Please Select
1st Dose
2nd Dose
How many COVID booster shots have you gotten?
Please Select
0
1
2
3
4
What is the date of your last COVID immunization?
-
Month
-
Day
Year
Date
Date of Birth
*
-
Month
-
Day
Year
Date
Please list all allergies. These may include allergies to certain food, medication, insect bites or stings, pollen, plants, or animals.
Please describe any dietary restrictions.
Please list any prescribed medication(s) currently being taken.
Please list any other health concerns that Indians for Collective Action should be made aware of.
Physician
*
First Name
Last Name
Physician Phone Number
*
-
Area Code
Phone Number
Physician Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Insurance
Insurance Company
*
Policy or Group Number
*
Subscriber's Name
*
First Name
Last Name
Subscriber's Relationship to Youth Program Participant
*
Will Your Current Medical Insurance cover your trip to India?
Are you covered for incidents and medical emergencies occurring in India?
*
Yes
No
Other
Submit
Should be Empty: