1. This Medical Form must be filled out by a physicianwho is not related to you and has known you for atleast 18 months. In addition, if you are under thecare of a specialist, (i.e. cardiologist, neurologist,psychiatrist, psychologist, social worker, physicaltherapist, etc.) you must submit a written report froma specialist detailing your diagnosis, treatment, andprognosis. Failure to submit such a report can resultin your expulsion from this program without anyreturn of funds.2. If you don’t have a physician, contact your localagency for instructions.3.If you will be taking prescription medication while onthis program you must submit a written report givingfull details of each medication. It is advisable to travelwith a written generic prescription for eachmedication. You must also bring two complete sets of your medication with you.4. If any changes take place in your medical oremotional condition within ten (10) days prior todeparture of this program, you must immediatelysubmit a full explanatory letter, signed by anappropriate, qualified medical or psychologicalprofessional, detailing your diagnosis, prognosis, andtreatment. Failure to submit such a report may resultin your expulsion from this program without anyrefund.5. It is our intention to rely on this completed form andsupplementary letters in determining your acceptanceand participation in this program. Omissions ormisstatements are at your risk and that of yourphysician(s) or therapist(s).6. Should you be found to have any condition, mentalor physical, that is not fully disclosed in this MedicalForm or in an accompanying letter from anappropriate, qualified medical or psychologicalprofessional, then:(a)you may, at the sole and absolute discretion of theprogram, be returned to the USA at your ownexpense, or be treated in the country(ies) you arevisiting, at your own expense, without monetaryrefund.(b)the leadership of this program and its sponsoringorganizations are hereby released from allresponsibility or liability of any kind whatsoeverarising out of any aspect of your medical historyand mental or physical condition.
Name of Applicant: .............................................. Email ........................................................
Medical Data Form
In Association With
OF THE LIVING INTERNATIONAL
Return to:Central Office
International March of The Living
2 West 45th Street, Suite 1500New York, NY 10036Tel: (212) 869-6800 Fax: (212) 869-6822Email: email@example.com Website: www.motl.org
PART 1 – FOR THE APPLICANT