Fall Trip 2019: Pre-Trip Profile

November 2 to November 9, 2019 | Comayagua, honduras

The form below is only for accepted fall trip participants. Please do not complete the form below unless you have been invited to do so by Mary Ellen Gannon.

Please 1) submit the form, 2) email all required documents (at bottom of form), and 3) mail a check for $575 made payable to VHC Medical Brigade to the address below by June 24, 2019.

VHC Medical Brigade
1069 W Broad Street, Suite 747
Falls Church, VA 22046

Name *
Name
Primary Phone *
Primary Phone
Alternate Phone *
Alternate Phone
Address 1 *
Address 1
Date of Birth *
Date of Birth
Emergency Contact *
Emergency Contact
Primary Phone of Emergency Contact *
Primary Phone of Emergency Contact
Alternate Phone of Emergency Contact *
Alternate Phone of Emergency Contact
Address of Emergency Contact *
Address of Emergency Contact
Name as Appears on Your Passport *
Name as Appears on Your Passport
Name for Name Tag *
Name for Name Tag
Health Insurance
Phone *
Phone
Please let us know if you have food/medicine allergies or food preferences.
What medications are you currently taking. Please let us know the medication and dosing.
Please let us know about any serious health conditions.
Required Documents *
Please email a copy of the following documents to volunteer@vhcmedicalbrigade.org and check the boxes below upon completion.
Electronic Signature
By submitting this form, I certify that the health information provided is true and correct to the best of my knowledge, and that I am sufficiently fit to handle the rigors of participating in a medical brigade project. I will promptly inform the VHC Medical Brigade of any changes or updates to the information provided on this form prior to travel.

Note: All participants will be registered with the US State Department.