Medical Form Name(Required) First Middle Last Date of Trip(Required) MM slash DD slash YYYY Father's Name First Last Day PhoneEvening PhoneProvide parent information for minors onlyFather's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mother's Name First Last Day PhoneEvening PhoneMother's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Spouse/Other First Last Day PhoneEvening PhoneSpouse/Other Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code If unable to reach any of the above, please list two additional contactsName First Last Relationship Day PhoneEvening PhoneName First Last Relationship Day PhoneEvening PhoneMedical Clinic and PhysicianName of Clinic PhoneClinic Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Name of Primary Care Doctor First Last PhoneDoctor's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Person Responsible for Payment First Last Relationship Name of Employer PhoneEmployer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Name of Insurance Company PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Policy Number Other Info HereConsent(Required) I hereby approve registration and give permission to take part in the Guatemala Trip. I voluntarily waive any claim against Work, Play, Love, Kim Melia, Faclilty Owners, staff, team leaders, volunteers, and any minors or contacts for any mishap or lost articles, or any and all accidents injuries and illnesses that may arise in connection with the Guatemala Trip activities. In addition, I realize that if WUiS leaders have to secure proper medical treatment for the above named person, they have my permission to do so. If those listed above cannot be reached at the above given numbers, I hereby authorize Kim Melia, and/or authorized persons to sign for necessary emergency and/or general medical treatment. This includes x-rays, injections, and surgery for the above named person during the time they participate in this Guatemala Trip. In a case of an emergency, all attempts will be made to contact the parent, legal guardian or spouse prior to medical treatment.Signature(Required) Reset signature Signature locked. Reset to sign again My signature verifies that all information given on this form is correct to the best of my knowledge. Δ Spread The Word Help us spread the word about Hogar Heroes by sharing this page with your friends and family! FollowFollowFollow VolunTOUR Join one of our scheduled trips to the orphanages or get in touch to learn how you can set up a trip to Guatemala with your group. Volunteer