Medical Form

DO YOU CURRENTLY OR HAVE YOU EVER SUFFERED FROM:

I confirm, by submitting this form, that the information that I have provided is a true and accurate account of my past medical history and any current medical conditions. If there are any changes to information provided on this form after submission I will inform Project Trust straight away via an email to Fra MacIntyre – fra.macintyre@projecttrust.org.uk. I am aware that failure to do so or the provision of any false information may result in my travel medical insurance cover being invalid and that Project Trust may cancel my placement and arrange my return to the UK. If I suffer an injury or illness during my placement or if additional information is required by a member of the Project Trust Team, I hereby give my permission for Project Trust to initiate treatment, and contact my GP, other relevant healthcare professional, key worker and/or next of kin. Project Trust and its partner health professionals respect the confidentiality of volunteers at all times. I consent to the medical information that I have provided in this form and information relating to medical conditions that arise during my placement, to be shared with Project Trust and its Overseas Representatives where required in my best interests.

You may put yourself at significant risk (and invalidate your insurance) if any information regarding your past medical history or current medical condition is excluded from this form, if false information is provided or if you do not notify us of any changes. You must immediately notify Project Trust of any changes in the information you have provided in this form by email to fra.macintyre@projecttrust.org.uk