Registration Form

Name:____________________________________

Date of Birth: ___________

Phone(s): __________________________________

Address: _________________________________________________

Email: _________________

Special interests in Thailand, hobbies,  etc.: _____________________________________________________

Any medical conditions affecting you or others on the trip (cardiovascular, lung, diabetes, hemophilia, allergies, seizures, psychological, etc.):
______________________________________________________________

______________________________________________________________

Any medications you are taking: ____________________________________

_____________________________________________________________

Can you walk 30 minutes at an easy pace without discomfort or excessive fatigue?

YES___ NO___ MAYBE__

Emergency Contact Name: __________________________________  Phone: __________________________

Do you want University of Natural Medicine Credits (two, in Nutritional Medicine) for this trip ($175)? ___

RELEASE FROM LIABILITY: Since I am participating in this trip and intercultural experience at my own risk, I hereby release MDCA, The University of Natural Medicine (UNM), and Dr. Adiel Tel-Oren from any liability in the event of injury, illness, death, or any other misfortune resulting from this trip to Thailand. I understand and accept the fact that this trip’s itinerary is subject to changes by the organizers, if deemed necessary for any reason and to the group’s benefit.

Signed: __________________________________________ Date: _________________

Please send this form with your check (payable to MDCA C/O Univ. of Nat. Medicine) to:
MDCA C/O Dr. T
2409   Lyndale   Ave   South
Minneapolis,   MN   55405  

STATEMENT OF INFORMED CONSENT: Since this trip occurs in a foreign country including remote areas, requiring various social, environmental, and health precautions, I hereby agree to read thoroughly, understand, and follow responsibly all the information and instruction given to me by Dr. Tel-Oren and/or MDCA and/or  The University of Natural Medicine, including the observation of ecological/ environmental/ nutritional/ social/ and cultural practices, the preparation for the trip, and the avoidance of behaviors risky to my health while under the stress of airplane transportation and exposure to physical challenges. I understand that this is necessary to prevent mishaps affecting all the other participants.

Signed: __________________________________________ Date: _________________