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PIES Medical Form
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Medical Allergies/Chronic Conditions
Your answer
Dietary Restrictions
Your answer
Other Medical Information
Please include any additional information that may effect your travel or participation in the service trip
Your answer
Physician's Name
*
Your answer
Physician's Telephone Number
*
Your answer
Health Insurance Provider
*
Your answer
Insurer's Phone Number
*
Your answer
Policy Number
*
Your answer
Group Number
*
Your answer
Please carry medical card with you at all times during the service trip.
Please submit a front and back copy of your current medical card.
email:
info@partnershipsineducation.org
mailing: P.O. Box 8074, Northfield, IL 60093
Have you received you tetanus shot in the last 10 years?
*
Yes
No
I don't know
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