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|Tropical Thailand Tour & Healing Retreat - Registration Form|
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Date of Birth: ___________
Phone(s): __________________________________Address: _________________________________________________
Special interests in Thailand, hobbies, etc.: _____________________________________________________
Any medical conditions affecting you or others on the trip (cardiovascular, lung, diabetes, hemophilia, allergies, seizures, psychological, etc.):
Any medications you are taking: ____________________________________
Can you walk 30 minutes at an easy pace without discomfort or excessive fatigue?
YES___ NO___ MAYBE__
Emergency Contact Name: __________________________________ Phone: __________________________
Do you want University of Natural Medicine Credits (two, in Nutritional Medicine) for this trip ($175)? ___
RELEASE FROM LIABILITY: Since I am participating in this trip and intercultural experience at my own risk, I hereby release MDCA, The University of Natural Medicine (UNM), and Dr. Adiel Tel-Oren from any liability in the event of injury, illness, death, or any other misfortune resulting from this trip to Thailand. I understand and accept the fact that this trip’s itinerary is subject to changes by the organizers, if deemed necessary for any reason and to the group’s benefit.
Signed: __________________________________________ Date: _________________
Please send this form with your check (payable to MDCA C/O Univ. of Nat. Medicine) to:
STATEMENT OF INFORMED CONSENT: Since this trip occurs in a foreign country including remote areas, requiring various social, environmental, and health precautions, I hereby agree to read thoroughly, understand, and follow responsibly all the information and instruction given to me by Dr. Tel-Oren and/or MDCA and/or The University of Natural Medicine, including the observation of ecological/ environmental/ nutritional/ social/ and cultural practices, the preparation for the trip, and the avoidance of behaviors risky to my health while under the stress of airplane transportation and exposure to physical challenges. I understand that this is necessary to prevent mishaps affecting all the other participants.
|Last Updated on Monday, 12 November 2012 15:23|