Medical Form

GENERAL INFORMATION

The information you provide to Spanish 2Go School in this form will be held in the strictest confidence, and will be used only to the extent necessary to provide necessary emergency medical care and/or evaluate fitness for travel. Please note that this may include transmitting your data overseas to any countries to which you may be visiting, but only as required. The collection, use, and disclosure of your personal information is governed by Spanish 2Go School Privacy Policy.

Who should complete this form?

All travelers must complete sections ‘A’, “B”, and “C”’. If you have indicated that you have a pre-existing medical condition you are required to complete section ‘D’ also. The more information Spanish 2Go School has, the more we may assist in the unlikely event of an emergency or provide other medical assistance. Please note Spanish 2Go School will assess the information contained in this form, and reserve the right to ask for a physician assessment for any passenger. Please ensure that you have confirmed with a medical professional that you are medically fit to embark on the travel you have booked.

Why do I need to complete this form?

Our immersion trip travels to a remote area where no sophisticated medical facilities exist. A medical emergency situation is extremely unlikely; however, should it arise we are armed with the necessary information to help you. If there are any changes to your physical/medical condition or otherwise to your responses below after your submission of the form to Spanish 2Go School, you must notify Spanish 2Go School immediately of that change. Spanish 2Go School reserves the right to request an up-to-date certification from a licensed physician in the event of such a change. If the information contained on this form is found to not be accurate as of your date of travel and you have not provided Spanish 2Go School with notice of such change, you may be removed from the tour with no refund or compensation payable.

What happens if I don’t complete this form?

In the event you have made a booking with Spanish 2Go School and subsequently are unable or refuse to complete this medical form for any reason by the final payment date as specified in our terms and conditions, Spanish 2Go School reserves the right to consider your booking cancelled as of that day and applicable cancellation penalties will apply.

How do I complete this form?

It is very important for your own health and safety that you complete all questions fully and truthfully. In the event of a medical emergency, the information you have provided could be crucial.

All passengers must complete sections ‘A’, ‘B’, ‘C’ If passengers answer yes to any question in section ‘B’, then proceed to section ‘D’. Part 1 of section ‘D’ must be completed by yourself, and Part 2 given to your medical practitioner to complete on your behalf. Each of you must then sign and return the entire document, sections ‘A’, ‘B’, ‘C’ & ‘D’.

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Step 1 of 2

SECTION A – GENERAL INFORMATION – Please complete all fields

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Name

Departure Date

SECTION B – MEDICAL INFORMATION – Please complete all fields

1.During the last 5 years, have you suffered any significant illness, been hospitalized or required regular care by a doctor?

If YES, please indicate reason

2. Have you ever had any of the following:

a) Tuberculosis, chronic bronchitis, emphysema or any other lung problems?

b) Asthma effects my everyday activities and/or I use medication or an inhaler regularly

c) High blood pressure, heart or respiratory problems, or rheumatic fever?

d) Gout or arthritis or any back, leg or foot problems?

e) Gastric or duodenal ulcer, colitis or intestinal trouble?

f) Epilepsy or fits of any kind?

g) Kidney or bladder disease?

h) Diabetes, cancer or tumour of any kind?

3. Do you have any physical limitations, handicaps or prosthesis? Do you have difficulty walking or use a device for mobility assistance such as crutches, cane or wheelchair?

If Yes, please specify:

4. Do you take medication or drugs related to a pre-existing medical condition?

5. Do you have any allergies, or reactions to any medication or drugs?

If Yes, please specify:

6. Are you pregnant?

If YES, how many weeks pregnant will you be at the time of travel?

7. Are you affected by any other pre-existing medical conditions not listed above?

If Yes, please specify

Please Note:
* If you indicated “YES” to any of the above questions (excluding question 5), you must now proceed to section ‘D’.

SECTION C – To be completed by all passengers

This section must be fully completed, please DO NOT OMIT any of the following details.

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Date of birth

Height:

Blood type

Weight:

Insurance Provider

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Insurance contact phone

Emergency contact name

Insurance policy number

Emergency contact phone

Medical History Terms & Conditions

I agree to this information being made available to Spanish 2Go School, LLC.

Although every city where Spanish 2Go School travels has hospitals and clinics. There are locations that have limited infirmary with basic medications and equipment, we ask you to complete this confidential medical report so that all due care may be provided. Participants with mobility issues, disabilities, heart problems, or other health concerns are advised not to join the tour, which would entail an unreasonable risk to your health and to the enjoyment of all those aboard. Should any such condition become apparent, the Company reserves the right to decline or accept or retain you and any other participant at any time before or during the trip.

I attest I am in good general health, and capable of performing normal activities on this Spanish Immersion Trip to Peru. I further attest that I am capable of caring for myself during the immersion trip, and that I will not impede the progress of the tour or the enjoyment of others. I understand that this tour will take me far from the nearest sophisticated medical facility and that all participants members must be self- sufficient. With that understanding, I certify that I have not been recently treated for, nor am I aware of, any physical or other condition or disability that would create a hazard to myself or other members of the immersion trip. I agree that should there be any change to the information I have given herein or to my physical or medical condition that I will notify Spanish 2Go School and, if requested, provide an up- to-date version of this completed form. I agree that any failure to provide full and complete medical information to Spanish 2Go School may result in the cancellation of my booking without further compensation payable to me for any loss.

I declare the answers to the above questions are true and complete. I agree to this information being made available to Spanish 2Go School, LLC.

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Traveler Signature

Date

SECTION D – MEDICAL PRACTITIONER FORM

If you indicated ‘YES’ to any question in section ‘B’, then please complete this section. Part 1 must be completed by yourself, and Part 2 given to your licensed physician for completion. At the bottom of the document, both yourself, and the physician must sign the document. Once completed, please return a signed copy to us.

Become familiar with the trip details, the physical demands, the location of the tour, and access to medical facilities should they be required. Please contact us if you require any additional information with respect to such details. Armed with these, we ask yourself and your medical practitioner to please complete the below:

Part 1 – to be completed by you

Your Name

First

Middle

Last

Please note information provided here may be forwarded onto select parties to ensure a safe and enjoyable tour. All information kept by the Company is done so in accordance with the Privacy Policy, and information will only be shared with those who need to know.

Part 2 – to be completed by a licensed physician

Name of Physician

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Phone

Doctor's Healthcare Facility Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please list any current medical conditions, infirmities, disabilities or physical limitations.

Please list all medication currently taken. If more room is required, please attach a separate list

If this patient has been hospitalized, or had surgery, at any time during the last 5 years, please tell us when and why

Medical History Terms & Conditions (copy)

I further declare the answers provided above to be accurate, complete and truthful.

I have read the trip details and am familiar with both the physical demands, and the remote location(s) of this trip. I am also aware that the hotel in the Cuzco region is not equipped with elevators and the attitude, may pose an increased risk to participants with mobility issues. With this knowledge, I have considered the suitability of this travel, and to the best of my knowledge believe this person to be physically and psychology fit to undertake this trip.

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Physician signature

Date

Patient signature

Date