2022/2023 HTCNE HEALTH FORM

2022/2023 HTCNE HEALTH FORM
REMEMBER TO HIT SUBMIT AT THE END OF THIS PAGE
What trip are you traveling with: *

Santa Cruz, Bolivia - Roser Team Jan 13 - 21, 2023 Ica, Peru - Rousso/Ransom Team April 14 - 23, 2023 Cartagena, Colombia / Gilman Team Feb 8 - 18, 2023
First Name *
Last Name *
Birth Date *

Month Day Year
Please list any allergies you have below or simply type "None" if you have no allergies. *
Please list any Significant Medical Problems/Conditions below or simply type "None" if you have no significant problems or conditions. *

List any medications you are currently taking or type 'none' in one of the boxes. For example: Aspirin 250mg 3x daily

Additional information regarding your medications, if needed
Have you been fully vaccinated against Covid-19?
Please upload a photo of your Covid-19 vaccination card

Browse Files

Cancel of
Name of Your Physician *
Phone # of Your Physician *
Emergency Contact (First/Last Name) *
Relationship: *
Best contact number to reach this person *
Should be Empty: