BRASS Medical Form
Please fill in this medical history form as completely as possible and return it with your application. The information will be kept strictly confidential and may be helpful to us in the event of a medical situation during your stay.
Accidents of any sort are extremely rare at El Pilar and the Program has a health and safety plan to address these concerns. Emergency medical care is available in San Ignacio, twenty-five minutes from the site and five minutes from our HQ.
It is recommended that all participants have a current tetanus booster, typhoid immunization and a malarial prophylactic such as Chloraquin.
PLEASE PRINT
Name _______________________________________________ Home phone ___(____)_____________________
Permanent Address: ____________________________________________________________________________
Date of Birth (Mo/D/Yr) __________________ Male___Female___
In case of emergency, please contact:
Name: _________________________________________________ Relationship: ___________________________
Address: _____________________________________________________________________________________
Phone: ___(___)______________________
Family Physician: ______________________________________________ Phone: ___(____)_______________
Insurance Co.: _____________________________________ Policy #: ____________________________________
Mailing Address: _______________________________________________________________________________
List any allergies or existing medical conditions:______________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
List any medications you take: ____________________________________________________________________
_____________________________________________________________________________________________
Signed: __________________________________________ Date: _____________________________