Medical Form

Name(Required)

First Middle Last

Date of Trip(Required)

Father's Name

First Last

Day Phone

Evening Phone

Provide parent information for minors only

Father's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mother's Name

First Last

Day Phone

Evening Phone

Mother's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Spouse/Other

First Last

Day Phone

Evening Phone

Spouse/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 contacts

Name

First Last

Relationship

Day Phone

Evening Phone

Name

First Last

Relationship

Day Phone

Evening Phone

Medical Clinic and Physician

Name of Clinic

Phone

Clinic Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name of Primary Care Doctor

First Last

Phone

Doctor's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Person Responsible for Payment

First Last

Relationship

Name of Employer

Phone

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name of Insurance Company

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Policy Number

Other Info Here

Consent(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)

My signature verifies that all information given on this form is correct to the best of my knowledge.

Spread The Word

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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