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WIESCO, Inc., Summer Teaching in Central Europe
Teacher Health Information
Name
Address:
Emergency Phone Numbers: (Weekdays) (Evenings/Weekends)
Name of Person to Be Contacted: Phone:
Name of Alternative Contact: Phone:
Do we have your permission to take you to a medical facility if needed?
Please identify any medical problems or medication you have that need to be aware of in case of an an emergency:
Are there any activities in which you may not be able to participate? Please list them:
I understand that there are dangers in involved in any trip and that the rules are for the safety of all travelers. I also understand that there are conditions and risks which may cause injury, and I agree that I am responsible for my own safety while on the trip and that North Western Travel Agency , WIESCO, Inc., or the Directors are not responsible for any injures that may occur. I specifically RELEASE, DISCHARGE, HOLD HARMLESS, in advance, all of the above named from any and all liabilities that may arise from the trip.
I have, and agree to maintain throughout the entire trip, valid and sufficient medical insurance. I understand that this is my responsibility and release all persons identified above from providing such insurance coverage. I further understand that foreign country medical facilities may not accept such insurance, that any medical services must be paid for in cash, and that I am responsible for reimbursing payment and submitting my own insurance claims.
I agree that I will accept and abide by all policies set by WIESCO, inc., Directors. This acknowledgement and assumption of risk and release in my responsibility and I hereby give my consent to full participation in the English language program.
Signature: Date:
Please return along with the completed Application by March 1, 2010.
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