Pre-existing Health Condition Addendum

If you indicated on your CCUSA application that you have a pre-existing health (physical or mental) condition, CCUSA requires that your sign this addendum and have the physician treating you for this condition complete and sign the Physicians Statement on Pre-existing Conditions. Both of these documents must be provided before your acceptance to the CCUSA program can be determined. I, ________________________________________________ , have the pre-existing condition of ________________________ ___________________________________________________________________________________________________________ I acknowledge that the CCUSA insurance will NOT cover any medical treatment or services that might be required as a result of this condition while I am on the CCUSA program. I have: a. Additional funds of _________________________________________ in the form of: Cash as attested to by the attached bank. Credit card as attested to by the attached credit statement. OR b. Supplementary insurance provided by ______________________________________________ to cover any expenses incurred due to my pre-existing condition as attested to by the attached insurance policy information. I further acknowledge that any health complications caused by my pre-existing condition while on the program can result in the ending of my CCUSA program and my return home if these complications result in my inability to continue the program activities.

Participants Signature: ________________________________ Date: _________________ CCUSA ID #

Rev.20.08.08