Fall Trip 2019: Pre-Trip Profile

November 2 to November 9, 2019 | Comayagua, honduras

Thank you for completing the form below. Please send 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 admin@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.