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Medical History Form

Please note:

  1. March of the Living reserves the right to reject an applicant on the basis of medical or psychological grounds. The MOTL medical advisory panel, made up of doctors and psychologists/counsellors who have previously participated on the MOTL program, will determine, as necessary, the eligibility of applicants.
  2. Failure to submit this Form on time, in full and with full disclosure of all medical and/or psychological information will jeopardise the possibility of you being accepted on the Program and in the event that non full disclosure has taken place but becomes apparent once you are already on the Program, could result in you being sent home (at your expense).
  3. A doctor and Psychologist/Counsellor will normally accompany participants on the Student March of the Living program. Both these professionals will be there as volunteer participants and are not employed by March of the Living. The doctor will be able to administer first aid and basic medication and will decide on and oversee the appropriate course of action for more serious events such as assessment in a hospital or consultation with a Specialist etc. Together with the psychologist/counsellor appropriate measures will be employed to maintain the psychological wellbeing of the participants.
  4. This Medical History Form is essential to help the doctor and psychologist/counsellor in being aware of any potential risks and therefore needs to be filled in with the utmost integrity and candour.
  5. If you are taking any regular medication it is advised to travel with 2 sets of such medication and a generic prescription from your doctor for this medication.
  6. If any changes occur in your medical or emotional conditions between now and the time of departure on the program, it is incumbent on you to supply a full explanatory letter to the accompanying doctor or to the MOTL coordinator. 
  7. All information provide by you and/or your MD and/or Specialists will be treated in confidence, however, may be discussed between the doctor and/or psychologist/Counsellor on the program and other MOTL supervisors where deemed necessary for the well being of the participant and the group. 

 

Please fill in the Form below (all fields are mandatory):


Sex:


 Date of Birth:


Do you consent to the March of the Living medical panel contacting your doctor / specialist / psychologist for further information regarding your medical and/or psychological suitability for the March of the Living program prior to consideration of your application?:



Do you consent to information being discussed between medical panel on the program and other leaders on the program?:



Allergies to:





Have you ever had an anaphylactic reaction?:



Health History:





























Are you able to participate in a strenuous program?: