Medical Information

Trip:   Today's Date:

STUDENT AGENCY SERVICES C x A
Dominican Republic, Tel: (809) 435-1980, (829) 875-4599, Fax (480) 247-4411
Apartado Postal Z-77, RD
Dominican Republic
E-mail: Inf@studentservicesdr.org
Standard Medical Information and Assumtion of SAS Form

Full Name:
Citizenship:
Passport No:     Blood Type:     D.O.B
Name of Insurance Co:     Policy No:
Street Address / City /
State or Sector / Zip or Postal Code / Country / /
Day Tel/Eve Tel/Fax: / /
Email:
 
Do you have a history of the following conditions? YES NO
Heart or circulatory disease, angina or heart attack
Raised blood pressure
Respiratory disease
Asthma/Hay fever
Epilepsy
Diabetes
Back injuries
Joint or dislocation injuries
Heat-stroke or severe dehydration
Fainting or blackout spells
Are you currently being treated for a medical condition? If yes, please clarify.
Please list any medications you take regularly:    
Are you pregnant?  
Please specify any allergies:
Insects: Medications:
Food :
Please specify any dietary requirements. (e.g. vegetarianism)
Is there anything else that we should know about that could affect your ability to participate in adventure activities?
If yes, please elaborate:
Assumption of SAS.
I understand that there are inherent risks of serious injury or even death possible with adventure tourism activities. I hereby, intending to be legally bound, for myself, my heirs, and assigns, executors and administrators, waive and release forever any and all liability, and all claims for damages against SAS Travel and Tours, Administrators, Volunteers, and/or Employees for any and all injuries and/or losses I/my son/my daughter/my ward may sustain associated with participation in SAS Travel and Tours & Student Agengy Services C x A's activities.
Please initial:
Assumption of Responsibility.
I understand that there are inherent risks in adventure travel, such as biking, hiking, cascading and/or whale watching. I acknowledge that part of the enjoyment and excitement of adventure travel is derived from participating in travel and activities with concepts of safety and comfort different from those of "everyday" life. I agree that it is my personal responsibility to fully participate in all instructional sessions before and during the tour, and to understand how the equipment works. I agree to immediately stop using the equipment if found to be damaged or not function properly. I assume responsibility for my own safe behavior, as well as a role in insuring the safety of those with whom I travel. Please initial:
Medical Treatment
Release. If medical care is required for me/my son/my daughter/my ward in conjunction with any SAS Travel and Tours & Student Agency Services, C x A activities or related transportation, and if normal permission is not available in a timely manner, the undersigned authorizes appropriate medical care as deemed necessary by emergency medical personnel, a physician, or the medical facility providing treatment.
Please initial:
Treatment Release.
In case of an emergency, I hereby authorize the following individual not traveling with me on SAS Travel and Tours activities to be contacted and ASSUME RESPONSIBILITY FOR ME IN CASE OF AN EMERGENCY that renders me incapable of communication or making competent decisions.
Full Name : Relationship:
City/State, Province/Zip, Post Code: / /
Day Tel/Eve Tel/Email: / /
I hereby certify to SAS Travel and Tours & Student Agency Services C x A, that I am solely responsible for my medical, psychological and physical condition for the duration of my tour with SAS Travel and Tours. I am unaware of any medical, psychological and physical problems that would, in any way, impair my ability to safely participate in this tour. Should any medical, psychological or physical problems arise during the course of my tour with SAS Travel and Tours, I am solely responsible for financial costs and expenses related to obtaining any and all medical, psychological and physical care that I may need. I am solely responsible for having adequate insurance coverage for any such care, including, but not limited to, adequate insurance coverage for the costs and expenses of trip cancellation, evacuation, baggage loss or damage, trip interruption, travel accident/sickness, and medical care. Please initial: , and check this box: I accept the above terms and conditions.
Signature of Parent/Guardian (if participant is under 18 years old):

Participant confirmation is partially dependent upon receipt of Medical Information & Assumption of Responsibility form.

This form is valid for all SAS activities within a 4-month period of the date indicated above. This information will be used to manage any health concerns that may arise while participant is on a SAS Travel and Tours activity. Alternative contact and medical information will be used in a medical emergency. If you have questions about the collection or use of this information, contact the Manager at (809) 435-1980, (829) 875-4599. (SAS) Student Agency Services C x A & Cento Cultural Turistico Guanin. Inc. in the Dominican Republic.
Please download this form and sent it by fax