I hereby certify that the Medical Information section is complete and full disclosure on any and all physical and Mental health issues have been included. It is the intention of the March of the Living to rely on this completed form and supplementary letters in determining my acceptance and continuation in this program. Omissions or misstatements are at my risk and that of my physician(s) or therapist(s).
~ Should I be found to have any mental or physical condition that is not fully disclosed in this Medical Form or in an accompanying letter from an appropriate, qualified medical or psychological professional, then ….
. …. I may, at the sole and absolute discretion of the program, be dismissed from the program prior to departure or returned to the USA at my or my parent's sole expense, or be treated in the countries I am visiting, at my or my parent's sole expense, and there shall be no refund of monies from this program.
. …. the leadership, employees, and staff of this program and its sponsoring organizations are hereby released from any and all responsibility or liability of any kind whatsoever arising out of any aspect of my medical history and mental or physical condition, whether or not disclosed.
All medication that I take regularly is detailed in this Application Form in the Medical Information Section.
~ If I will be taking prescription medication while on the trip, I will submit a written report giving full details of each medication.
~ I will travel with a written generic prescription for each medication.
~ I will also bring two complete sets of my medications with me if possible.
To participate on the March of the Living, I will submit a signed copy of the March of the Living physical examination form, found on the www.moldallas.org website filled out by my personal physician along with a copy of my Immunizations record from my school. Two 2"x2" passport photos, A copy of the current inside picture page of your passport and a copy of your medical insurance card
Deposit, as noted, is also required.