Date
*
-
Year
-
Month
Day
Date
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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17
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19
20
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22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
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2013
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1921
1920
Year
Age
*
Gender
*
Female
Male
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
*
First Name
Last Name
Primary Emergency Contact Information
*
First Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Emergency Contact Information
*
First Name
Last Name
Secondary Emergency Contact Relationship
*
Secondary Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Insurance Provider
*
Company Name
Medical Insurance Policy Number
*
Insurance Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Subscriber
*
I, {fullName}, do hereby authorize and permit MedSchoolCoach, LLC to bring me to the hospital or established clinic for evaluation and/or treatment. I understand that, if possible, the primary physician will be contacted so that he/she may participate in this treatment through various communication methods in the event of an emergency. In the event that the primary physician is not available, I hereby authorize the physicians and staff on duty at the hospital or clinic to treat me in the event of such an emergency (illness, accident or other injury). I understand that every reasonable effort will be made to contact the parent/guardian or designated emergency contact person in the event of such an emergency, but should these attempts fail, treatment may proceed. I further understand that in order for MedSchoolCoach, LLC to have the fullest opportunity to assist me, I must complete the contact information in this application. I realize and accept that all costs incurred as a result of this treatment may be billed directly to me if proper payment information is not included or insurance not approved for international care. By my signature below I release MedSchoolCoach, LLC, its entire staff and volunteers, the medical staff of the treating hospital or medical facility, local ambulatory services, clinical staff, nurses, drivers, and support personnel from any and all liability resulting from any action caused by such an emergency treatment. Signed on: {date}.
*
Signature
Page 1 of 2
Physician Information
Physician Name
*
First Name
Last Name
Physician Phone Number
*
Format: (000) 000-0000.
Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical History
*
Rows
Yes
No
If yes, explain
Diabetes
Hypertension (high blood pressure)
Adult or congenital heart disease/heart attack/chest pain (angina)/heart murmur/coronary artery disease. Any heart surgery or procedure.
Family history of heart disease or any sudden heart-related death of a family member before age 50.
Stroke/TIA
Asthma
Lung/respiratory disease
COPD
Ear/eyes/nose/sinus problems
Muscular/skeletal condition/muscle or bone issues
Head injury/concussion
Altitude sickness
Psychiatric/psychological or emotional disorders
Behavioral/neurological disorders
Blood disorders/sickle cell disease
Fainting spells and dizziness
Kidney disease
Seizures
Abdominal/stomach/digestive problems
Thyroid disease
Excessive fatigue
Obstructive sleep apnea/sleep disorders
List any other medical conditions, surgeries, or hospitalizations not covered above.
*
Allergies
*
Rows
Yes
No
Explain?
Medication
Food
Plants
Insect bites/stings
Animal
Other
Immunizations
*
Rows
Yes
No
Date of Immunization
Tetanus
Pertussis
Diphtheria
Measles/mumps/rubella
Polio
Chicken Pox
Hepatitis A
Hepatitis B
Meningitis
Influenza
COVID-19
Other (i.e., HIB)
List all medications currently used, including over-the-counter medications
Rows
Medication
Dose
Frequency
Reason
1.
2.
3.
4.
5.
I, {fullName} do hereby release MedSchoolCoach, LLC, its directors, and all subsidiary staff and volunteers from any and all liability resulting from the involvement of {fullName} in programs known as MedSchoolCoach or
Ultimate Med Immersion
. I understand clearly that staff, volunteers, and students may be interacting with, but not limited to, each other, the general public, patients, medical personnel, and medical students and/or exposed to, but not limited to, hospital rooms, operating rooms, morgues, and cadavers in a developing nation. I understand that although all necessary precautions will be provided through MedSchoolCoach, LLC, I agree to also take all necessary precautions for keeping safe and healthy. I have filled out all necessary forms required for attendance and have provided appropriate forms to our Primary Physician to be filled out and returned to MedSchoolCoach. Signed on: {date}.
*
Signature
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