Volunteer Emergency Contact Form

Thank you for volunteering to serve at BMC and taking the time to complete this form! The information we are asking for is critical to your safety while you are serving here. Please complete it to the best of your ability.

Your info is kept confidential and will only be seen by our medical volunteer coordinators (Dr. Heidi & William Haun) and our guesthouse coordinator (Francis Ackom) unless a medical emergency does arise.

If you have any questions you can contact us at [email protected].

Your Name (required) 

Your Email (required) 

Your Phone 

Your Mailing Address 

Your Date of Birth (required) 

Dates of your Trip to Ghana (required)  until


Travel Health Insurance

It is very important that all volunteers have international travel health insurance. Such policies cover everything from personal property theft to emergency medical evacuation. If you do not have such coverage, we highly recommend (and use ourselves) Gallagher Charitable which costs around $3/day (price sheet)

Insurance Company (enter "n/a" if none) 

Insurance Contact Number 

Policy Number 

Enrollment Number 


Medications

What malaria prophylaxis are you taking?

What is your blood type?

List current medications and reason for taking:

Do you have any existing medical conditions we need to be aware of? (e.g. diabetes, epilepsy, allergies, etc)


Emergency Contact #1 (required)

Name (required) 

Relation 

Email 

Phone #1 (required) 

Phone #2 


Emergency Contact #2

Name 

Relation 

Email 

Phone #1 

Phone #2 


Residency/Med School Contact (if applicable)

Institution/Program Name 

Point of Contact's Name 

Point of Contact's Title 

Email 

Phone 


Other Notes or Comments