Name as appears on passport*
Birthday*		January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937
Blood Type
Do you have medical insurance?*		no yes
Health Insurance Company
Policy Holder's Name
Health Insurance Policy Number
Participant's Primary Care Physician
Physician's Phone Number
Physician's Address
Does your insurance cover you outside of the US?*		I'm not sure no yes
List any major surgeries within the last year:*
List any medications you take:*
List any drug reactions or special needs:*
List known allergies or known reactions:*
Do you have any coronary (heart) medical history? If yes, please describe:*
Do you have any history of diabetes?*
Do you have any physical limitations and/or conditions that will affect you on this trip?*
Do you have any other health conditions that are important to share?*