STM Individual Health Form


Please fill out the following form completely and then click 'Send' at the bottom. The form must be completed prior to your trip and will be sent to the Every Day Ministries STM Coordinator to make sure we are ready for your arrival.

Personal Information

Group Name: Group ID:
Last Name: First Name:
Birthday: Male Female
Address: City:
State: Zip:
Email: Phone:

Church Information

Church Name: Pastor:
Address:
Years Attended:
Email: Phone:

Emergency Contact Information

Name: Relationship:
Address: City:
Email: Phone:

Medical Information

Please completely fill all the following fields. We must know all this information should the participant require medical attention.

1. From what company do you have medical insurance?

Note: Please bring along a photocopy of the insurance card (front and back) on the mission trip.

2a. Do you have any allergies, reactions to medications or foods, or any other medical limitations? YES NO
2b. If yes, please identify and explain:

3a. Are you currently taking any medications (prescribed or otherwise)? YES NO
3b. If yes, what are you taking and what condition is it for?

4. What was the date of your last tetanus shot?

5a. Do you have any limiting disabilities or physical handicaps (temporary or permanent)? YES NO
5b. If yes, please explain:

6a. Have you had any major illness in the past five years? YES NO
6b. If yes, please identify and explain:

7a. Are you currently under the doctor's care or have been under a doctor's care in the last year? YES NO
7b. If yes, please identify and explain:

8. If you have any other medical conditions or disabilities we should be aware of, please describe in detail.