Houston Teen Israel Experience 2025 - Physician Medical Form

Physician Medical Form
Please refer to our policy on immunization/vaccination requirements for participation. All forms must be completed within 12 months of the program departure date.
Name*

First NameLast Name
Physician Name*

First NameLast Name
Physician Phone Number*

Area CodePhone Number
Dentist Name*

First NameLast Name
Dentist Phone Number*

Area CodePhone Number
Insurance Company*
Group Number*
Policy Number*
Name of Policy Holder*
1) Download a copy of this health form here.
2) Have a physician complete the form
3) Take a picture or scan the form to this section
4) Upload a copy of your updated vaccination report
Signed doctor's form*

Browse Files

Cancelof
Immunization/Vaccination Records*

Browse Files

Cancelof
Authorized Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: