Intern Medical Release Form

* Participant Name (full name)
* Address
* City
* State
* Zip Code
* Phone
* Email
* Date of Birth mm/dd/yyyy
* Insurance Company
* Policy Number
* Emergency Contact Person
* Emergency Contact Phone
* Emergency Contact Person #2
* Emergency Contact Phone #2
* Beneficiary (for insurance purposes)
* Relationship of Beneficiary
Medical Allergies
Medications Being Taken (please list all)
Medical Problems or Other Pertinent Information
Special Requests
I release Global Partners in Peace and Development, together with the adults in charge, from any and all claims resulting from injury or damage that may be sustained while participating in the activities of Global Partners in Peace and Development. I understand that, in the event medical treatment is required, every effort will be made to notify the emergency contact person. However, if they cannot be reached, I give my permission to Global Partners in Peace and Development or an Associate to secure the services of a licensed physician to provide the care necessary, including, anesthesia, for my well being.
* I have read the information above and agree to the waiver of liability/consent to treat	* I have read the information above and agree to the waiver of liability/consent to treat
* Participant Name
* Today's Date
* Internship Country:	Haiti Jordan Slovakia India US
* Dates of Internship


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