XXXII. MEDICAL INFORMATION FORM/ DOCTORS NOTE OF GOOD HEALTH.
La Suerte & Ometepe Biological Field Station

•This form medical clearance/release note should be returned to La Suerte and Ometepe Biological Field Station PO BOX 55-7519 Miami FL 33255-7519 it can also be faxed to 305-666-7581 Bring a copy with you to the field site. Hand-delivered to staff at the FIELD COURSE site.
• If student is under 18 or married we have parental/spouse authorization on all statements noted, parents/spouse must sing bellow.
• Your safety is important to us! In order to participate in the program all students must fully understand and agree to the terms of this agreement by signing bellow.
• I am of sound mind, in good health and no physical or mental conditions that would hinder or prevent me from participating in the program. I understand that keeping health limitations confidential can result in dismissal.
• The students Dr or Dr specialist must complete the Medical information bellow and note all known pre-existing medical conditions PRIOR to arrival at any of our field sites.
• Before acceptance into our program, La Suerte/Ometepe Biological Field Station or medical personnel on location have the student’s authorization speak to your Dr with out restrictions if it is necessary.
• During the class session, La Suerte/Ometepe Biological Field Station or medical personnel on location have the student’s authorization speak to your Dr with out restrictions if it is necessary.
• To ensure the safety of all students, La Suerte/Ometepe Biological Field Station has the right to deny acceptance into the program based on recommendation from your Drs, health limitations that would endanger the student or a medical record that indicates a history of mental health issues that may endanger the student or disrupt the learning environment.
• To ensure the safety of all students, medical complications on site may result in an early return home. Students who suffer injuries or become ill at our sites will be treated at local clinics and based on medical evaluation sent home. La Suerte/Ometepe Biological Field Station has the student’s authorization speak to the students Dr with out restrictions if it is necessary.
• La Suerte and Ometepe Biological Field Stations are not responsible for Medical expenses that may occur due to sudden illnesses.
• La Suerte and Ometepe Biological Field Stations are not responsible for added expenses related to emergency transportation to the clinics or emergency evacuation to the USA.
• Should a student feel ill at any time during his or her stay it is their responsibility to bring this condition to the attention of staff members IMMEDIATELY, so that an appropriate response can be initiated.
• La Suerte and Ometepe Biological Field Stations have authorization to request medical or hospital records.

I Student name: __________________ have read, understood and agree to the statements above. Bellow I voluntarily sign in agreement to the statements and release of information above.
Student legal name: __________Middle _______Last ___________ Signature X____________________

Date:
(Married or under 18 require a signature) Parent/Spouse signature X_____________________________Date:
Emergency contact: ______________________Tel____________Cell__________email________________Relation__________
Student Name______________________Tel____________Cell__________email________________
Course Name: _______________________________Year __________________

Circle session # 1 May 25 to June 19, # 2 June 22 to July 17, #3 July 20 to Aug 14, or Winter Dec 27 to Jan 18 Year:
Dr use only:
Travel, studies and the tropics can be demanding on the mind and body. All participants to this program must be in good health and have no physical or mental conditions that would hinder or prevent them from participating in the program. Your patient’s safety is very important we need to be made aware of all pre-existing medical conditions or limitations. The student your patient has authorized for us to contact dr or specialist if further information before or during the class.
Please mark the following accordingly.

Asthma_______Hay Fever_______Convulsions_______Diabetes_______Heart_______
______Drug/alcohol_______Allergies_______Stings/InsectBites________Penicillin______
Mental health____________Other___________________ Has the patient been Hospitalized? _____
Please mark the following accordingly.
? Yes the patient examined today is in good physical and mental health and cleared to travel abroad? _______
? No we recommend the patient not travel at this time due to current health limitations._________________
• If yes was noted on any medical conditions please include limitations or restrictions on back page. _______
• If yes was noted on any Hospitalization please explain.___________________________________________
• ? Specialist ? General: Doctor evaluating the patient: ________________Tel: ___________ Fax:__________Email:
Dr Signature: Date:
General Doctor name: _______________ Clinic name: ________Tel: _____________Fax: _______________Email
Specialist’s Name: _______________clinic ____________Tel: _________________ Fax: _______________Email
Dr Signature: Date: ____________________