Health Form

HEALTH FORM

YWAM NEWCASTLE | YWAM TAHLEE
Please fill in your details as accurately as you can. This form should take about 20 minutes to complete. We use this information to determine if our programs will put you at a heightened risk in any area. There may be times that we ask follow-up questions based on your answers, to determine whether our programs can adequately meet your needs. Your information will be stored securely, and will not be distributed without your prior consent.
Applicant Name*

First NameLast Name
Email*
example@example.com
Applying for:*
Height (cm)*
Please convert to centimetres (cm)
Weight (kg)*
Please convert to kilograms (kg)
Medicare Number
(Australian residents only)
Emergency Contact:

Please complete using the details of the person that you want to be contacted in case of emergency.
Emergency Contact:*

First NameLast Name
Relation to you:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country*
Mobile/Cell Number:*
Please include country code (ie +1 for USA/Canada, +61 for Australia etc)
Medical History

Have you ever had (or do you currently have) any of the following? Please select all from the list that apply, and give an explanation in the section below.
AnaemiaArthritisBlood Pressure IssuesCancerChronic ConstipationConcussion/ Head InjuriesDiabetesEpilepsyFainting SpellsHay Fever/AsthmaHepatits A, B, or C (specify)HIV or AIDSInsomniaIntestinal TroublesKidney DiseaseParalysisRecurrent DiarrhoeaRecurrent Headaches/MigrainesShortness of BreathSkin Conditions (specify)Stomach UlcersVenereal DiseaseNone of the aboveOther
Explanations for above:
Mental Health History
Do you have any previous or current mental health conditions (including schizophrenia, bipolar, eating disorders, addiction, etc?)*

YesNo
If yes, please list which, and the year you were diagnosed with each condition.
In the past three years, have you had depression or anxiety that was treated by medication and/or counselling?*

YesNo
If yes, please describe.
In the past three years, have you ever attempted to harm yourself or someone else?*

YesNo
If yes, please describe.
Overall Health
Are you able to carry out reasonably strenuous work on a daily basis?*

YesNo
Do you have any conditions—behavioural, mental, or physical—that would limit your ability to fully participate in international outreach activities? For example: walking long distances daily, hiking, trekking, going to a medically underserved area, carrying luggage on long journeys etc*

YesNo
If yes, please specify:
Do you suffer from any condition that is currently under treatment by a doctor?*

YesNo
If yes, please specify:
Prescription Medications
Please list all current prescribed medications you take (daily and as needed) including name, dosage, and frequency.
It is a requirement of enrolment that you will continue to take any prescription medications for the duration of the course. Please bring a full supply of medication with you that is adequate for the duration of the course, including any international travel portion of your program. Bear in mind, your brand of medication may not be available in Australia or in any countries that you travel to as a part of the course.
Allergies and dietary needs
Do you have any special dietary needs?*

YesNo
If yes, please specify:
Please note that YWAM Newcastle and Tahlee may not be able to accommodate to all food preferences. We will do everything we can to provide healthy, fresh and nutritious food while being mindful of dietary needs.
Do you have any allergies?*

YesNo
If yes, please specify:
Do you have any allergies that require the use of an adrenaline/ epinephrine injection? (aka an "EpiPen"?)*

YesNo
If yes, please specify:
If yes, please upload an Anaphylaxis Plan prepared by a Doctor.

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Is there anything else regarding your health or well being you feel your staff or ministry leader should be aware of?*

YesNo
If yes, please specify:
Immunisation History
There are several immunisations that can be helpful in prevent sickness while overseas. Please come up-to-date according to your country’s immunisation schedule. If you choose not to we may require you to sign an additional waiver form. We may advise that our travelling students and staff receive immunisations prior to travel. This is done in consultation with local medical professionals.

It is common for our travelling teams to have Hepatitis A and B, Tetanus boosters, and Typhoid. It is preferential (although not required) that full courses of these shots be administered by your personal medical practitioner before arrival, as they are able to keep records of your shots and make recommendations based on their knowledge of your health circumstances.

Please fill in the dates as best you can. You may need to consult your local health care professional. If you need to do that, you can submit this form a second time and we will compile the information as needed.

Have you received these childhood immunisations?

Rows	Completed	Not completed
Diphtheria, Tetanus & Pertussis (5 doses): (DTPa/dTpa/DTap/Td)
Polio (3-5 doses): (IPV/OPV)*
Measles, Mumps, & Rubella (2 doses): (MMR)
Meningococcus (1 dose): (MenC/MenCCV/MCV)
COVID-19 (2+ doses)

Please write the dates you received these shots:

Rows	1st Dose	2nd Dose	3rd dose	Booster
Hepatitis A
Hepatitis B
Cholera
Typhoid
Yellow Fever
Tetanus
COVID-19

Signature

By signing this document, I acknowledge that the information provided is true and accurate to the best of my knowledge at the time of writing.
Name*

First NameLast Name
Signature*

Clear
Should be Empty:

Emergency Contact:

Medical History

Mental Health History

Overall Health

Prescription Medications

Allergies and dietary needs

Immunisation History

Signature