WAIVER FORM

AUG 10-14

AUG 24-28

*REQUIRED FIELDS

** ALL medications must be brought in the original container with doctor’s instruction

HEALTH HISTORY

check conditions and describe below

Details on above:

HEALTH INSURANCE

Please upload your health insurance:

FRANCE

**EUROPEAN HEALTH CARD - If you have it

SPAIN

ITALY

OTHER

MEDICAL AUTHORIZATION

Medical Authorization And Insurance Coverage

Medical Authorization And Insurance Coverage This Health Information Is Correct. In the event the emergency contact cannot be reached in an emergency during the program dates noted on this form, I HEREBY GIVE PERMISSION to the physician selected by BREAD OF LIFE EUROPE, to secure proper treatment, to order injection, anesthesia, dental care and/or surgery for the participant. I GIVE PERMISSION for BREAD OF LIFE EUROPE to provide for the participant a certified First Aid provider to administer First Aid and over the counter medication as needed for illness or injury as well as any medication noted. I AGREE that photocopies or faxes of this complete form are to be considered legally valid and binding for trips off the property. I AGREE to obtain and maintain personal insurance covering the participant in the program with appropriate waiver of subrogation rights to reflect the fact that the participant’s personal insurance shall supercede and be used before any insurance coverage that may be provided by BREAD OF LIFE EUROPE, In the absence of the aforementioned insurance, I AGREE to pay all costs of rescue and /or medical services as may be incurred by the participant.

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So come with an EXPECTANT Heart!! ❤️‍🔥
See you soon! 🤜🏼🤛🏽