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HEALTH FORM
Name _________________________________________________________________

Address _______________________________________________________________

Phone # _____________________________  Home Church ____________________________

Date ______________________________    Trip Location _______________________________
 
MEDICAL HISTORY

ARE YOU CURRENTLY TAKING MEDICATIONS?  YES_______     NO________

If so, list medication and reason for taking them __________________________________

__________________________________________________________________________

List previous surgeries _______________________________________________________

__________________________________________________________________________
 
PHYSICAL ASSESSMENTS

AGE _______     WEIGHT ________     B.P. ________     BLOOD TYPE ___________

HEARING ________     VISION ________     CONTACTS _________

WHAT WOULD YOU LIKE TO DO WHILE IN MEXICO

CARPENTRY _____     CEMENT _____     BLOCK LAYING ______     ELECTRICAL _____
COOK ______     HOUSE-TO-HOUSE MINISTRY ______     CHILDREN'S MINISTRY _____
WOMEN'S MINISTRY _____     STREET MINISTRY _____     INTERCESSORY PRAYER _____
CLOWN MINISTRY _____


TEE SHIRT AND/OR CAP ORDER FORM
$10     MEDIUM_____     LARGE _____     X-LARGE _____
$12     XX-LARGE _____
$15     XXX-LARGE _____
$5      CAPS

PLEASE PUT ___________________________________ IN A ROOM WITH ME.
 PLEASE MAIL THIS FORM AND RISK FORM, WITH ROOM MATE REQUEST, INCLUDING DEPOSIT TO:
SMARTT ASSEMBLY OF GOD
P.O. BOX 69
SMARTT, TN 37378
FAX: 931-668-2475
 
 
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