Medical Release Form
Participant Date of Birth
Date Format: MM slash DD slash YYYY
Please read carefully and sign to indicate agreement:
I hereby certify that to the best of our knowledge, that all personal health information submitted to Achva is complete in all its details. I realize that any condition, mental or physical, that the applicant is found to have originating prior to the Achva tour, and which is not described fully in submitted materials, will be due cause for the applicant's return home, or treatment on location, solely at my expense, and that Achva or the National Council of Young Israel and its representatives or agents have neither responsibility or liability arising out of such condition.
All medication to be provided to the applicant is at my own expense and, if known beforehand, has been detailed in my submitted materials.
I assume all responsibility and will indemnify and hold harmless Achva, the National Council of Young Israel, its officers, directors, agents and employees for any claims, suits, costs or liability for any damage including personal injury caused to or by my child.
In case of a medical emergency, the Achva staff or healthcare professional selected by them has my authorization to order whatever medical or surgical treatment is deemed necessary for the health and safety of my child.