Bernie’s Pura Vida Fund Medical Form
General Information
Bernie’s Pura Vida Fund grants provide funding for children and youth, up to their 22nd birthday, with a primary physical disability (examples include spina bifida, spinal muscular atrophy, moderate to severe cerebral palsy, amputees, permanent injuries leading to disabilities, muscular dystrophy, etc.) who would not otherwise be able to travel to Costa Rica without special transportation, trained staff, accessible accommodations, and accessible equipment and activities.
Applicant’s name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of last clinical check
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does the applicant have a primary PHYSICAL disability impacting mobility that requires multiple accommodations to successfully travel?
Yes
No
List the student’s disability/medical condition and current symptoms
Does the applicant use any of the following medical equitment?
Manual wheelchair
Respiratory support (CPAP, BiPAP, continuous oxygen)
Electric wheelchair
Medications requiring 24/7 refrigeration
Crutches
Emergency medications (seizure, glucagon, epi pen, Factor for hemophilia)
Braces
Feeding tube
Other
Safety is of the utmost importance and the vendors we work with have decades of experience assisting travelers with all sorts of disabilities to travel to Costa Rica. Is travel safe for the applicant?
Do you have any specific concerns?
In case of limited funding, priority will be given to applicants that fit the following categories. Do any of these apply to your patient?
Spina Bifida
OEIS Complex/Cloacal extrophy
Epilepsy
Adopted from the foster care system
Currently in the foster care system
Aged out of the foster care system
Medical Professional Information
By signing below I agree that travel is appropriate for the applicant.
Yes
No
I have more questions
Certified/licensed professional name
First Name
Last Name
Specialty
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Signature of certified/licensed professional
Submit
Submit
Should be Empty: