Confidential Health Information
Health In Harmony has been hosting visitors since 2007, and we have had very few issues with participant health and safety. In order to maintain this strong track record, we commit to providing thorough information about health and safety issues (focusing on prevention) and clear expectations about engaging with our programs and communities. We ask that you, too, provide clear, thorough information so that your trip can be a safe, rewarding experience. We will use this information only as it is relevant to planning your trip and in case of emergency, and it will be kept confidential in a secure database.
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Email *
First name *
Last name *
Gender *
Health Information
Please fill in all information clearly and completely. Keep in mind that we gather this health information so that Health In Harmony and ASRI staff are adequately prepared to respond should you require medical attention. This information is otherwise kept confidential.
Are you fully vaccinated against COVID-19? (please note that proof of vaccination is mandatory to participate in the program) *
What type of vaccination did you receive? *
Primary health insurance provider name and ID/group number: *
Do you have any past or present medical conditions? Please include relevant details on date of last occurrence, symptoms, treatment plan, and restrictions to program activities. *
List all prescription medications, over-the-counter, inhalers, and herbal supplements, etc. that you are currently taking and the dosage/frequency of each (eg vitamin C, 1000mg, daily) *
Please provide an overall summary of your present physical and mental health. *
I certify that all of the above information is true and complete to the best of my knowledge. I understand that additional information may be requested based on my responses. I give permission to Health In Harmony and ASRI to communicate relevant information concerning my health should I require care.
By typing my name below I am agreeing to the above statements. *
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