Summer 2011 Medical Spanish Enrollment Form

Summer 2011 Medical Spanish Enrollment Form

Name *

First

Last

Date *

YYYY

Address *

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

Email *

Home or Cell Phone number *

###

####

2nd Phone Number

###

####

License No. for CEH Certificate (RN,LAc,RT,etc.)

Room Preference *

Smoking

Non-Smoking

Roommate Name(s)

Many rooms can accommodate more than two people should you want to share with a larger groups of friends or family.

If using this form for one family or group please supply the requested information for all members of your group.

Please have each adult attendee and guest sign a medical information and consent form, and parents please fill one out for your minor guests.

As this program involves travel and different climates, we want to have some basic health information before any problems develop.

Emergency Contact Name *

First

Last

Emergency Contact Address *

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

Emergency Contact Email *

Emergency Contact Home or Cell Phone Number *

###

####

Emergency Contact 2nd Phone Number

###

####

Please list any medical conditions you have:

Please list any food or medication allergies you have:

Digital Signature *

By entering your name here you agree to the following:

First

Last

freely requests admission to the Medical Spanish Program and optional side trips offered by Deepa Health Farm in Costa Rica July 3 through July 10, 2011.

I am a responsible adult and I will take full legal and financial responsibility for my own actions and travel arrangements to and within Costa Rica. I will not hold Deepa Health Farm or its agents, sub contractors and representatives responsible for any actions in accordance with all the laws of Costa Rica. Furhtermore, I realize that participating in this group event my photograph may be taken by others, and I also give my consent for Deepa Health Farm SA to use my photo publicly when discussing this program.

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