HEALTH INFORMATION
For Participants in Labor-Religion Delegations


We ask this information in order that we can plan for any special needs of delegation members. Your answers to any questions will not necessarily affect your eligibility or ability to participate in the delegation but can help us to take measures to reduce the risks of serious health concerns during the course of the delegation. Please note that the Labor Religion Coalition of New York State is not responsible for health emergencies that may occur during your delegation experience.

Please print, complete and return this form to us (along with the PARTICIPANT INFORMATION DOCUMENT) at International Project, LRCNYS, 800 Troy-Schenectady Road, Latham, NY 12110-2455. Call us at 518/ 213-6000, ext. 6294 for more information.

1. General Health: Excellent: _______ Good: _______ Fair: _______

2. Please list any chronic health problems (i.e. diabetes, heart condition, disabilities, asthma, depression, ADHD), and other health-related concerns: ___________________________________________________________

___________________________________________________________

___________________________________________________________

3. Please list any allergies you are aware of.

MEDICATIONS: _______________________________________________________

FOODS: _____________________________________________________________

OTHER: _____________________________________________________________

4. Are you currently under a physician’s care or taking any prescription medication? Please describe:
____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

PLEASE NOTE: Be sure to bring enough of any prescription medicines with you on the delegation, in their original containers which list your health care provider’s name. It’s also a good idea to bring a paper copy of any essential prescriptions.

health insurance

Please check with your health care provider or insurance carrier to ensure that you have health coverage during your travel.

5. Health Insurance Carrier:

______________________________________________

6. Primary Insurance Holder (name listed on the policy):

______________________________________________

7. Relationship to you:

______________________________________________

8. Policy number: __________________________


9. Group number:__________________________
Be sure to bring your insurance card with you.

Immunizations

No immunizations are required for travel to Border areas of Mexico. Please be sure, however, that your routine immunizations are up to date. These include: Measles Mumps, Rubella (MMR), DPT (includes tetanus) and Polio. In addition, you may want to discuss Hepatitis A vaccine with your health care provider.

For travel to Dominican Republic, Nicaragua or Southern Mexico, you will need the following immunizations and/or preventive medication: Hepatitis A, Hepatitis B, Typhoid, Malaria, Rabies (to be discussed with your health provider or travel clinic).

For more information, visit www.cdc.gov/travel, a travel medicine clinic or your health care provider.

signature: _________________________ date:_____

parent or guardian signature:
______________________________________
(If you are under eighteen years of age when we travel)
Revised 10/2008