Medical

Fields marked with * are required.

Please re-enter your name.

Please list any food allergies.

Please list any health problems.

I understand that it is my responsibility to check with my physician concerning immunizations.

Yes

I understand it is my responsibility to check with my health insurance provider regarding out-of-country coverage, and that Project Hope is not responsible for any medical expenses incurred while on the trip.

Yes

Who may we contact in case of an emergency?

Relationship to Applicant

Phone

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Medical

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