Medical Information Form - 2017 Cambodia
Please complete this form in its entirety.  All information will be kept in strictest confidence and will be available only to PhotoEnrichment Programs, Inc. d.b.a. PhotoEnrichment Adventures (PEA), personnel on a need-to-know basis, as well as to necessary authorities in the case of an emergency.

We strongly recommend that you contact your personal physician for recommendations regarding your individual health requirements while traveling. You should also be up-to-date with all of your shots, including tetanus and standard immunizations.  

If you haven't already, please start thinking about updating any of your vaccinations that may be out of date (check with your doctor) and see the Centers for Disease Control website (http://wwwnc.cdc.gov/travel) for more specific information about the country or countries to which you'll be traveling.

TIP: If you're located in Southern California and you have questions, consider contacting the Santa Ana Health Department at 714-557-5599 or 714-647-0401 for a consultation on what vaccinations you'll need.  You should make an appointment as soon as possible as often there's a waiting period to schedule a time to meet.  If located elsewhere, look up your local health department to do the same.
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First Name *
Middle Name
Last Name *
Your Height *
Your Weight *
Date of Birth *
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DD
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YYYY
Have you taken out medical insurance that will cover you while traveling and/or that will provide evacuation in the case of an emergency? *
We strongly recommend that you purchase medical and travel insurance to protect your health and your investment in this trip.
If yes, please provide that information, including policy number(s) and all contact info.
Please evaluate your overall health. *
How would you rate your general level of stamina? *
Do you have any medical conditions or physical limitations we should be aware of? *
If you answered YES above, please explain in more detail.
What is your blood type? *
Please list any medication(s) you are currently taking and in what dosage(s).
Do you have any food allergies or dietary restrictions that we should be aware of?
Emergency Contact Name *
Emergency Contact telephone number. *
Emergency Contact telephone number - alternate.
Emergency Contact email address.
Primary Doctor's Name *
Primary Doctor's telephone number. *
Is there anything else you'd like us to know related to your medical information?
I certify that I have provided all necessary health information on this form and that my participation in this program won't pose an unnecessary risk to myself or others. *
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