SOLT Medical Mission Form | Society of Our Lady of the Most Holy Trinity

The upcoming SOLT Missionary volunteer year requires the activity level of a person in good health. Your mission may be taxing. It is important to consider the differences you will encounter in the diet of your mission site, and the climate. All of these factors may aggravate certain health conditions.

Please answer honestly and fully the questions below to furnish SOLT Missions with an accurate profile of your current health. We may request a medical release statement from your doctor based upon the information you provide below.

SOLT Missions Medical Form

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1. List any physical and/or mental conditions that may limit or impact your ability to perform the ministry for which you have applied under the conditions listed above. *

2. List any current medical conditions that you know will require extended medical treatment or surgery in the future? *

3. List any surgeries or major health problems you have experienced in the past 2 years: *

4. List any prescription and non-prescription medications you are currently taking: *

5. List any medications or foods you know you are allergic to: *

6. Please explain the reason for any care you have received from a doctor during the past year. *

7. Do you have any special dietary needs? If so, please explain: *

8. List any limits you place on yourself to avoid physical or medical problems: *

Emergency Contact

Full Name (First and Last) *

Relationship *

Phone Number *

Signature: *

The above information is a true representation of my current health status. SOLT may use the above information to represent my medical needs to a doctor in the event of an emergency. Please type your full name below to electronically sign this form.

Date: *

First Name *

Last Name *

Mission Location *

Leave this field blank