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Health & Info Form for Cuba
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* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
Do you suffer from any of the following?
Asthma
Epilepsy
Diabetes
Are you under any treatment or medications that should be continued on the tour?
Your answer
Do you have any allergies to any food or medications?
*
Yes
No
If yes to previous question, please specify:
Your answer
Do you have any food restrictions (religious or other)?
*
Yes
No
If yes to previous question, please specify:
Your answer
Doctor's Name:
*
Your answer
Doctor's Telephone Number:
*
Your answer
Person to be notified in case of an emergency:
*
Your answer
Relationship of emergency contact:
*
Your answer
Home Telephone number of Emergency Contact:
*
Your answer
Cell Phone number of Emergency Contact:
Your answer
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