Overseas Volunteer Medical Clearance Form
Complete this form to provide necessary health and readiness information for overseas volunteer participation.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Overseas Destination Country
*
Intended Volunteer Role or Work Type
*
Do you have any chronic medical conditions?
*
No chronic conditions
Yes, cardiovascular
Yes, respiratory
Yes, diabetes
Other (please specify)
List any current medications
List any allergies (e.g., medications, food, environment)
Immunization Status: Are your routine vaccinations up to date?
*
Yes, all required vaccinations are up to date
No, some vaccinations are pending
Unsure
Emergency Contact Name and Phone Number
*
Medical Clearance Attestation: I confirm that the information provided is accurate and I consent to this information being reviewed for the purpose of medical clearance for overseas volunteer work.
*
I agree and give permission for review
Submit Medical Clearance
Should be Empty: