COAR Peace Mission * 4395 Rocky River Drive * Cleveland, Ohio 44135-2569 * (216) 252-5572 * coarpm@sbcglobal.net

 
Medical Information and Release to Treat Form
for Visitors to the
COAR Children's Village in Zaragoza, El Salvador
Printable version
Form date: March 29, 2007
Instructions:
Print and sign the completed medical information and release to treat form and mail it to COAR in Cleveland:
 
COAR Peace Mission
4395 Rocky River Dr.
Cleveland, OH 44135
If any required information is left blank, or if you cannot answer “yes” to any items of the release to treat you may be ineligible to travel to COAR. Please discuss any problems or questions with your group leader.

Privacy Statement:
COAR understands that privacy concerning personal medical information is important. We will make every effort to keep this information confidential. Once our office verifies that the form has been completed, it will be placed in a sealed envelope with your name on it. Two sets of envelopes will be carried on the trip by the group leader and the guide. If the information is not needed, the copies will be destroyed, or returned to you, if requested.

1. Your Personal Information
* required
Full Name: *
_________________________________________ Age: * _______
Travel Dates : *
________________________________________________________________________
Group or organization: *
________________________________________________________________________
Group leader : *
________________________________________________________________________
* one of these phone numbers is required:  
Work/day Phone: *
________________________________________________________________________
Home/evening Phone: *
________________________________________________________________________
Cell Phone: *
________________________________________________________________________
Fax:
________________________________________________________________________
E-mail:
________________________________________________________________________

2. Medical Information
* required
A.
 Describe any existing medical condition or limitations (if none, write "none"):
B.
 List all prescription medications you are currently taking, or may require, and the condition(s) for which they are required (if none, write "none"):
C.
 List any allergies, especially to drugs or insects (if none, write "none"):
D.
 List recent immunizations (if none, write "none"):

Date of last Tetanus Booster ____/_____/_____






3. Release for Medical Treatment
* required
Yes
No
 Place a check mark in either the Yes or No box for each item to indicate that you understand the release for medical treatment. Please discuss any questions or concerns about these items with your group leader.*
   



For minor children: I authorize ____________________________________________________ to make decisions regarding my minor child regarding admittance to any hospital or medical facility for diagnosis and treatment. He/she may request and authorize physicians, dentists, staff, technicians, or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken.
For adults: If I am unconscious or otherwise unable to participate in my treatment I authorize


__________________________________________________________________ to make decisions regarding admittance to any hospital or medical facility for diagnosis and treatment. He/she may request and authorize physicians, dentists, and staff, technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken.

    For both adults and minors: I agree to accept responsibility for any medical costs which may result from my participation or the participation of my monir child.
    For both adults and minors: I have read this release and indemnification agreement and understand its meaning. This release is intended to bind my heirs, representatives, successors, assigns and administrators.

I have carefully reviewed the foregoing and this form in its entirety, and by signing below agree to its
terms with full understanding of its meaning and effect.


Signature of participant: _______________________________________ Date: _________


Signature of parent or guardian : ________________________________ Date: _________

Parent or Guardian Information:

Print name of parent or guardian: ________________________________________________


Address, Street, City, Zip: ______________________________________________________


Phone numbers: _____________________________________________________________


E-mail or other contact information: ______________________________________________
 
 
Return signed original to:
COAR Peace Mission
4395 Rocky River Dr.
Cleveland, OH 44135