Emergency details

Your Name

First Last

Your Email

Arrival Date

Program Housing Address (eg. 197 Lower Main)

Emergency Contact

First Last

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship to you:

Their Phone #:

Their Email:

It is a requirement for all interns to pre-purchase travel medical insurance. If you already have a policy back home, make sure you double-check that your coverage extends to South Africa and that it covers COVID-related testing and medical treatment abroad. For more information go to https://legacy.vacorps.com/knowledge-base/travel-medical-insurance/

Name of your insurance provider

Name of the insurance policy holder

First Last

Insurance policy number or ID

Insurance emergency phone number

Do you have any present medical problems, under the regular care of a physician or other medical health provider?

Please describe:

Do you have any dietary restrictions?

Please describe:

Do you have any allergies or reactions to any medications, foods, insects, or other agents?

Please describe:

Does your health prevent you from participating in any physical activities?

Please explain

Are you taking any prescription medications regularly?

Please list them here

Are you under the regular care of a psychiatrist, psychoanalyst or other mental health provider for any mental, emotional, or nervous disorder?

Please explain

Is there anything else you feel we should know?

Please explain

Passport Number

Passport Expiry Date

Please upload a copy of your passport

Max. file size: 64 MB.

Country of Issue

I hereby certify to VACorps that I am solely responsible for my medical, psychological and physical condition for the duration of my program with VACorps. I am aware of any medical, psychological and physical problems that would, in any way, impair my ability to participate in the program. Should any medical, psychological or physical problems arise during the course of my internship with VACorps, I am solely responsible for obtaining any and all medical, psychological and physical care that I may need. I am solely responsible for paying for the costs and expenses of any such care. I am solely responsible for having adequate insurance coverage for any such care, including, but not limited to, adequate insurance coverage for the costs and expenses of trip cancellation, evacuation, baggage loss or damage, trip interruption, travel accident/sickness, and medical care.*

Yes

By typing your first and last name, you are acknowledging that the information you gave us is accurate and true*

First Last

Intern Emergency Details