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Tours
Trips Treks & Travel
Cabarete, Dominican Republic, tel: (809)543-3371,
fax: (809)571-0995, info@4tdomrep.com, 4tdomrep.com
Standard Medical Information and Assumption of Risk Form
| First
Name |
Last
Name |
Citizenship |
| Passport
No. |
D.O.B. |
Blood
Type |
| Name
of Insurance Co. |
Policy
No. |
| Address |
Zip/Postal
Code |
| City |
State/Province |
Country |
| Day
Tel |
Eve
Tel |
Fax |
| Email |
Medical
Questionnaire
The adventure activities in which you will be participating are
challenging and will require a reasonable level of fitness, strength
and endurance. It is your responsibility to ensure that you have
the appropriate level of fitness. These activities are not recommended
for those with major disabilities, illnesses or infirmities. If
you have any questions regarding your ability to participate,
please consult your doctor to ensure that you are sufficiently
fit and healthy. You should take into account that medical and
other facilities in the Dominican Republic are likely to be inferior
to those of your home country.
| 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 |
|
|
| Faint
or blackout spells |
|
|
| Blood
or bleeding disorders |
|
|
| Are
you currently being treated for a medical condition? |
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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)
|
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Is
there anything else that we should know about that could affect
your ability to participate in adventure activities?
If yes, please elaborate.
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Assumption
of Risk and Waiver
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 Tours Trips
Treks & Travel S.A., 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 Tours Trips
Treks & Travel S.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 Tours Trips Treks & Travel S.A. activity
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 Tours Trips Treks & Travel S.A. activities
to be contacted and ASSUME RESPONSIBILITY FOR ME IN CASE OF AN
EMERGENCY that renders me incapable of communication or making
competent decisions.
| Name |
Relationship |
| Address |
| City |
State/Province |
Zip/Postal
Code |
| Day
Tel |
Eve
Tel |
Cell/Pager |
| Fax |
Email |
I
hereby certify to Tours Trips Treks & Travel & Aguatours
Dominicana, S.A. that I am solely responsible for my medical,
psychological and physical condition for the duration of my tour
with Tours Trips Treks & Travel. 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 Tours Trips Treks & Travel, 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.
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Please
print name
|
Signature
|
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Signature
of Parent/Guardian (if participant is under 18 years old)
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Please
fax or mail to Tours Trips Treks & Travel. Participant confirmation
is partially dependent upon receipt of Medical Information &
Assumption of Responsibility form
This
form is valid for all Tours Trips Treks & Travel Tours 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 Tours Trips Treks & Travel
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)543-3371.
Tours Trips Treks & Travel is operated with Aguatours Dominicana
S.A. in the Dominican Republic.
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