Mission Trip Participant Application Form

Medical and Health History
Please describe your health, including any physical or dietary limitations
List any allergies (food, medicine, environment, insects, etc)
List any sleeping conditions you have (snoring, insomnia, etc.):
Are you able to walk at least two miles and able to carry your own bags? Yes? No?
If no, please explain
Date & provider of last tetanus shot?
Name of Primary Care Physician
Telephone:
Current Medications (both prescription and over the counter medications):
(use separate sheet, if necessary)
Name of Medication Dosage (strength, frequency) Reasons for taking medication
Check All That Apply:
Diabetes Heart trouble Fainting
Asthma Epilepsy Emotional issues
Physical disability High Blood Pressure Bee/wasp reactions
If you answered yes to any above conditions please explain:
List any medical, first Aid or CPR Training & Dates:
HPPC Mission Trip Application Form Page 2 of 6