Esperanza Volunteer Medical Waiver

Volunteer Medical Information, Treatment Authorization, and Release Form

Esperanza International Inc., Fundación Esperanza de México A.C., and Posada Esperanza A.C., (together with their respective directors, officers, employees, agents, and volunteers, collectively, “Esperanza”)
Volunteer Contact Information
Name*

First NameLast Name
Date of Birth*

MMDDYYYY
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Country CodeArea CodePhone Number
Email*
example@example.com
Group with whom you will be volunteering*
Emergency Contact
Emergency Contact*

First NameLast Name
Relationship*
Emergency Phone #1*

Country CodeArea CodePhone Number
Emergency Phone #2*

Country CodeArea CodePhone Number
Volunteer Pertinent Health History
Please list Medical Conditions: *
Such as asthma, diabetes etc. and any information needed in the event you are unable to answer questions.
Current Medications*
Date of Last Tetanus Shot *

MonthDayYear
YesNo
If yes, what was the precipitating substance and what was the treatment?*
Esperanza works in the greater Tijuana region of Mexico, and volunteer activities may occur in environments that involve construction sites, tools, vehicles, uneven terrain, and other inherent risks of injury or illness. Emergency treatment will be provided through available doctors, clinics and hospitals in Mexico when necessary. Please remember that caution, careful planning and prevention on your part will greatly reduce the need for emergency medical treatment. Bring your medications, EpiPen, inhalers or other needed treatments with you.
VERY IMPORTANT INFORMATION – PLEASE READ AND ACT –
Esperanza REQUIRES all volunteer participants to maintain, at their sole cost, active international medical insurance (including emergency medical evacuation and repatriation coverage) during their volunteer experience with Esperanza in Mexico. Not all insurance providers include out of country coverage. Please contact your insurance provider in advance of your event to learn about your out of country coverage & procedures for treatment, and you agree to provide proof of such coverage upon request and acknowledge that Esperanza may deny participation or remove you from activities if you fail to maintain required coverage. If you don’t have out of country coverage, inexpensive travel insurance is available online. For more information on what we require, please visit our website at: https://esperanzaint.org/insurance/
Insurance Provider*
Member Number*
Doctor's Name*
Doctor's Phone*

Country CodeArea CodePhone Number
Sign Form
I hereby authorize the leader(s) of the group I am participating with or any representative, agent or staff of Esperanza to consent to medical or dental treatment as they reasonably determine is necessary under the circumstances on my behalf, including but not limited to any X-ray examination, anesthetic, medical/dental or surgical diagnosis or treatment, and hospital care to be performed by a licensed physician, surgeon, medical clinic, or hospital in Mexico or the United States; provided that I remain responsible for all related costs.*

Agree
Agree
I hereby release, waive, and forever discharge Esperanza, its affiliated entities, officers, directors, employees, agents, and volunteers from any and all liability, claims, demands, actions, or causes of action, whether known or unknown, arising out of or relating to any first aid, medical/dental treatment, or service rendered, or the decision by any representative or agent of Esperanza to exercise the power to consent to medical or dental treatment or to disclose information, except to the extent caused by Esperanza’s gross negligence or willful misconduct.*

Agree
Agree
Date Signed*

MMDDYYYY
Signer's Name (Name of Volunteer OR Name of Parent/ Legal Guardian if Volunteer is a Minor)

First NameLast Name
Signature of Volunteer OR Signature of Parent/ Legal Guardian if Volunteer is a Minor
reCAPTCHA Verification*
Form Revised 01/15/2026
Should be Empty:

Volunteer Medical Information, Treatment Authorization, and Release Form

Volunteer Contact Information

Emergency Contact

Volunteer Pertinent Health History

VERY IMPORTANT INFORMATION – PLEASE READ AND ACT –

Sign Form