Ocean’s Edge Intern | Medical Form Fields marked with an * are required Traveler’s Full Name: * Medical Insurance Information Medical Insurance Information:If your insurance plan does not cover you internationally or has Iimited coverage while you travel, we highIy recommend that you purchase International Medical Insurance for the duration of your trip. Coverage is inexpensive and can be purchased for any length of time. Plans that include important benefits, such as evacuation by plane in the event of an emergency, are offered online through companies like IMGlobal, Good Neighbor Insurance, or the Missionary Travel Association. **Please provide information for the medical insurance plan that will cover you as you travel. Name of Insured: * Membership/Policy Number: * Group Number: * Name of Insurance Company: * Company Phone Number: * Emergency Contact Information Emergency Contact Information: In case of an emergency, please notify: First Emergency Contact’s Name: * Relationship: * Phone * Second Emergency Contact’s Name: * Relationship: * Phone * Important Medical Information Important Medical Information: It is always a good idea to notify your physician of any plans to travel overseas and consider his/her suggestions for vaccines, preventatives and precautions relating to your health. For Costa Rica specific recommendations, please visit the CDC website. 1. Are you currently ill or undergoing any medical treatment (including medications)? * Yes No If yes, explain: 2. Do you have any allergies (foods, medications, hay fever, etc.)? * Yes No If yes, explain: 3. Do you have any daily mandatory medical needs? * Yes No If yes, explain: 4. Do you have any conditions not already mentioned that might hinder you during this trip? * Yes No If yes, explain: 5. Do you know your blood type? * Yes No If so, what is it? 6. Is your tetanus shot current? * Yes No Date of last tetanus shot: Agreement I acknowledge that I have filled out the attached Medical Information Form to the best of my knowledge and understand that Ocean’s Edge does not provide health or medical insurance in connection with this internship. I have read Ocean’s Edge recommendations concerning international medical insurance and consulting with my physician prior to travel.I agree that I will be financially responsible for any bills incurred as a result of medical treatment, including emergency medical treatment and/or transportation to a medical facility, in connection with my participation in the internship program. I further authorize Ocean’s Edge or any of its staff, missionaries, partners or representatives to render or obtain such emergency medical care or treatment for me as may be necessary should any injury, harm, or accident occur to me while participating in the internship program. Digital Signature * Today's Date * If you are a human seeing this field, please leave it empty.