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

 
COAR Release Form for visitors to the
COAR Children's Village in Zaragoza, El Salvador
Form date: September 17, 2010
Instructions:
Print, sign (or have your parent or guardian sign) the completed release 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 terms of the release information, you may be ineligible to travel to COAR. Please discuss any problems or questions with your group leader.
 

1. Your Personal Information
* required
Name: *
________________________________________________________________________
Passport number: *
______________________________________ Country: _________________________
Address Line 1: *
________________________________________________________________________
Address Line 2:
________________________________________________________________________
City, State, Zip: *
________________________________________________________________________
* one of these phone numbers is required:  
Work/day Phone: *
________________________________________________________________________
Home/evening Phone: *
________________________________________________________________________
Cell Phone: *
________________________________________________________________________
Fax:
________________________________________________________________________
E-mail:
________________________________________________________________________
Travel Dates : *
________________________________________________________________________
Group or organization: *
________________________________________________________________________
Group leader : *
________________________________________________________________________

2. Emergency Contact Information
* required
Emergency Contact Full Name: *
________________________________________________________________________
Relationship to you: *
________________________________________________________________________
Work/day Phone: *
________________________________________________________________________
Home/evening Phone: *
________________________________________________________________________
Cell Phone:
________________________________________________________________________
E-mail:
________________________________________________________________________
Additional information:
________________________________________________________________________
 


________________________________________________________________________
 
________________________________________________________________________
3. Release Information
* required
Yes
No
 Place a check mark in either the Yes or No box for each item*
    I voluntarily join the trip to El Salvador, named above. In that capacity, I will be traveling to El Salvador, volunteering at COAR Children's Village and visiting pertinent sites.
    I grant to COAR Peace Mission, COAR Children's Village, and the Archdiocese of San Salvador, its representatives and employees the right to take photographs or videos of me and my property in connection with my visit to COAR, including preparation for the trip, while in El Salvador, and events afterward and further authorize them and their assigns and transferees to copyright, use, and publish the same in print and/or electronically.
    I agree that COAR Peace Mission, COAR Children's Village, and the Archdiocese of San Salvador, may use such photographs and videos of me without my name for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
    I grant to COAR Peace Mission, COAR Children's Village, and the Archdiocese of San Salvador, its representatives and employees the right to use any photos or videos that I take and give to them for any purpose such as publicity, illustration, advertising, and web content, with or without attribution.
    I recognize and assume all risks of travel to, from, and within El Salvador, a country with extreme poverty and crime and often very difficult conditions.
    On behalf of myself, my family, heirs, representatives, executors, administrators and all other persons making any claim by any reason of any relationship to me, I hereby release and hold harmless COAR Peace Mission, the Archdiocese of San Salvador, COAR Children's Village, and any of their affiliates, subdivisions, officers, directors, trustees, teachers, employees, advisors, agents and representatives from any claims, damages, costs, including attorney fees, or other liabilities resulting from personal injury, property damage, or other losses of any kind in any way connected with participation in this program.
    I understand that sponsoring organizations take no responsibility for my medical care or the availability of medical services during this trip.
    I understand that if my behavior endangers the children or staff of COAR, my group, or myself, or if my behavior is disruptive to the group or to COAR, as determined by the group leader or the Director of COAR, I may be asked to leave COAR and El Salvador at my own expense. I understand that if my minor child is asked to leave, he/she will be accompanied by an adult, also at my expense.

4. Medical Information
* required
Travel Insurance Company name: * ____________________________________________________
Travel Insurance policy number: * ____________________________________________________
Travel Insurance contact phone number: * ____________________________________________________
Medical Insurance Company Name:
_____________________________________________________
Policy Number:
_____________________________________________________
Emergency Authorization Phone Number:
_____________________________________________________
Primary Care Physician Name:
_____________________________________________________
Primary Care Physician Phone Number:
_____________________________________________________

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 ____/_____/_____



5. Release for Medical Treatment
* required

Yes
No
 Place a check mark in either the Yes or No box for each item*
   
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.


6. General Understandings

* required
Yes
No
 Place a check mark in either the Yes or No box for each item to indicate that you understand the conditions you are likely to encounter on this trip. Please discuss any questions or concerns about these items with your group leader.*
    I understand that travel in El Salvador may be difficult and uncomfortable, hot, dusty, and with unexpected delays. COAR and other sites require walking and climbing. Electricity at COAR and excursion sites is limited an unreliable. I feel that my general physical health is sufficient for this trip.
    I understand that COAR exists to serve the best needs of impoverished children. I want to participate in COAR's mission by respecting the children's schedule, honoring any requests made by the housemothers, teachers, or staff regarding the well-being of COAR, and bringing any concerns about my understanding of these requests to my group leader.
    I understand that El Salvador has a tragic and complex past, through which many people I meet will have lived and suffered. I will ask any questions about that time and receive the answers humbly and with the understanding that I may not have the language ability or experience to judge the actions or opinions of those Salvadorans who share their experiences with me.
    I understand that the needs of my group must be respected and I will follow the established schedule, participate in group activites and reflection times, and be considerate of my fellow-travellers.
    I understand that if my behavior endangers the children or staff of COAR or my group I may be asked to leave COAR and El Salvador at my own expense.

7. Thought-provoking Questions
* required
Please take a moment to consider these four (4) questions. The answers need not be long, but we hope they will be well-considered so that your experience at COAR will be as rich as possible:
A.
 What do you understand to be the purpose of your group's visit to COAR?
B.
 What are you curious about regarding COAR, El Salvador, the developing world, or the poor?
C.
 What do you feel you can bring to your group and what do you hope to gain from the group?
D.
 How do you plan to follow-up your experience at COAR?


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