Emergency medical form

Name: _________________________________ Passport #: _________________________

Name of emergency contact: _________________________________________________

Relationship: ____________________________ E-mail: __________________________

Day phone #: _________________________ Evening phone #: ______________________

Name of doctor: _________________________ Phone #: __________________________

Blood type: _______________

Do you have any special medical conditions that we should be aware of during your trip? (Allergies, low or high blood pressure, etc.)

Do you have any special dietary needs?

List all prescription medication you are taking:

Insurance carrier:
(Make sure your policy covers you overseas and includes emergency medical evacuation.*)

Name: _______________________________________ Policy #: _____________________

Contact phone #: ___________________________________________________________

In the event of a medical emergency, I hereby authorize those in charge to take me to the nearest licensed physician, medical center, or hospital to secure the necessary treatment to protect my well-being. I will be responsible for all medical costs not covered by my insurance.

Signature __________________________________ Date: __________________________

If under 18, signature of parent/guardian: ______________________________________

*EMM requires overseas and emergency medical evacuation coverage for all of our short-term assignments overseas. We strongly recommend emergency evacuation coverage especially if the service location is in a place where expert medical facilities are not readily accessible.