March of the Living South Africa
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Home
About
March of the Living
The Team
Adult Delegation
Programme Info
Young Adult
Visa & Travel Info
Apply
Gallery
Youth Delegation
Programme Info
Visa & Travel Info
Apply
Testimonials
Blog
Gallery
Medical Form
It is our intention to rely on this completed form and supplementary letters in determining your acceptance and continuation in this program. Omissions or misstatements are at your risk and that of your doctor or therapist.
Should you be found to have any condition, mental or physical, that is not fully disclosed in this medical form or in an accompanying letter from an appropriate, qualified medical or psychological professional, then:
(a)
You may, at the sole and absolute discretion of the program, be returned to South Africa at your own expense, or be treated in the country(ies) you are visiting, at your own expense, and there shall be no refund of money paid for this program and
(b)
The leadership of this program and its sponsoring organisations are hereby released from all responsibility or liability of any kind whatsoever arising out of any aspect of your medical history and mental or physical condition.
If any changes take place in your medical or emotional condition within ten (10) days prior to departure of this program, you must immediately submit a full explanatory letter, signed by an appropriate, qualified medical or psychological professional, detailing your diagnosis, prognosis, and treatment.
*
Indicates required field
Name
*
First
Last
Contact Email
*
Family History
Father's Name
*
First
Last
If deceased, please specify date and cause of death:
*
Mother's Name
*
First
Last
If deceased, please specify date and cause of death:
*
Sibling Name(s)
*
If deceased, please specify date and cause of death:
*
Check all medical conditions that apply to your health history:
*
Anemia
Arthiritis
Asthma
Bleeding disorder
Chemical dependency
Chicken pox
Convulsions/Neurological disorders
Diabetes
Eating disorders
Epilepsy
Eye ailments
Fainting
Frequent colds
German measles
GI/Stomach problems
Headaches
Heart ailments
Kidney ailments
Measles
Menstrual problems
Mononucleosis
Motion sickness/Vertigo
Mumps
Orthopaedic fractures
Pneumonia
Poliomyelitis
Psychological problems
Rheumatic fever
Scarlet fever
Sinusitis
Sleep walking
Thyroid condition
Tuberculosis
Tumors
Please elaborate on all boxes checked above:
*
Do you have any allergies:
*
All food on the trip is Kosher, but we have very limited capacity to cater for dietary requirements. Please indicate if you have any and we will try to accommodate:
*
Have you undergone any operations or sustained any injuries? If yes, give details, including dates, names and addresses of doctors and hospitals:
*
Are you taking any medication now? If so, please state name of medication, name of doctor and condition being treated:
*
Condition of health:
*
Date and nature of last illness:
*
Describe any disabilities or restrictions:
*
Are you able to participate in a strenuous program?
*
Yes
No
Have you ever been in any kind of physical therapy? If so please indicate:
Person consulted:
*
Dates
*
Profession
*
Reason
*
Have you ever been in any kind of psychological or social therapy? If so, please indicate:
Person consulted
*
Dates
*
Profession
*
Reason
*
Submit