Professional Fellows Questionnaire

Participant Background Information
1. Full Legal Name*
(Your legal name as listed on your passport. This is how it will appear on such documents as a certificate of participation, airline ticket etc.):
Prefix First Middle Last
2. Name/Nickname
If applicable, please enter the name or nickname you want to be called on this Program:
3. Birthdate*
4. Your Mobile*
country code - city code- phone number
In case of emergency, whom should Legacy contact?
6. Contact's Name*
First Last
7. Contact's Relationship to you*
8. Contact's Home Phone*
country code - city code- phone number
9. Contact's Mobile*
country code - city code- phone number
10. Contact's Email*
Alternate emergency contact, if person listed above is not reachable.
12. Alternate Contact's Name*
First Last
13. Alternate's Relationship to you*
14. Alternate's Home Phone*
country code - city code- phone number
15. Alternate's Mobile*
country code - city code- phone number
16. Alternate's Email*
17. Legacy factors in time each day for people to observe prayers during business hours. We will also suggest local mosques where you can attend Jumah prayer each week. We recommend that you download an app on your cell phone to provide local prayer times and indicate the direction of the Qibla, as you will not find this information readily available in U.S. hotels and businesses. Is there anything further Legacy can do to support the practice of your faith?*
18. List your dietary restrictions or preferences, if any. (Please state 'None' if not applicable in the answer box below)*
(For example: no shellfish, no dairy, halal, kosher, vegan, etc)
19. Do you smoke?*
- Yes
- No
Please estimate your daily use*
(For example: 1 pack a day, only at night after dinner, etc.)

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Health Questions
All medical information is kept confidential and only shared with others on a “need to know” basis. You will be provided with medical insurance to cover the costs of medical care in the US, should the need arise. It will not cover the costs of routine medical care or treatment for any pre-existing medical or dental condition. (Details will be provided at a later date.)
20. Do you have any allergies?*
- Yes
- No
Please list your allergies (If none, please state 'None' in the answer box below)*
(For example, allergic to pollen, shellfish, peanuts, dogs, cats, mold, medications)
Please list any treatment for allergies you typically use. (If none, please state 'None' in the answer box below)*
(If you require epinephrine for treating severe allergic reactions, please note this and be sure to bring this with you.)
Allergy Treatment
21. Do you have any physical limitations we should be aware of? Please list any. (If none, please state 'None' in the answer box below)*
(For example: hard of hearing, difficulty walking up stairs, difficulty standing for long periods, etc.)
22. Do you have any on-going (chronic) or current medical conditions? Please list and elaborate how you are currently managing this condition. (If none, please state 'None' in the answer box below)*
(For example: diabetes, asthma, heart disease, recent fracture which may affect mobility, etc.)
23. Have you been hospitalized in the past three years?*
- Yes
- No
Please describe reasons and actions taken.*
24. Please list any medications you take on a regular basis, including dosage. (If none, please state 'None' in the answer box below)*
NOTE: Please be sure to bring enough medication to last your entire U.S. stay.)

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Step 1 of 4

Participant Background Information

Health Questions

Technology Use

Program Assessment