Natural Solutions Foundation Volunteers

Valley of the Moon^TM

VOLUNTEER PARTICPANT AGREEMENT

HEALTH INFORMATION

PRINT NAME:______________________________________________________________________

DATE OF BIRTH:_____________________PLACE OF BIRTH:______________________________

CELL PHONE NUMBER:_______________________EMAIL_______________________________

IN CASE OF EMERGENCY CONTACT: NAME__________________________________________

ADDRESS:_________________________________________________________________________

PHONE:______________________________________EMAIL_______________________________

PLEASE PRINT

I certify that I have the following major medical conditions:___________________________________

I certify that I am in good health and expect to be able to carry out the tasks which I agree to as a Valley of the Moon^TM Volunteer. I have no health problems which could prevent me from doing so and do not expect to require medical care during my stay. If I require medical care while in Panama, I understand that any costs associated with such care are my sole responsibility. I further understand that neither the Natural Solutions Foundation nor Valley of the Moon^TM provide insurance of any type and that all health care and related costs are my responsibility.

I agree to hold Natural Solutions Foundation, the Valley of the Moon^TM Eco Demonstration Project, the Trustees, Directors and Employees of these organizations harmless in the event of illness, injury or other adverse eventuality.

Signature:________________________________________________

Date:____________________________________________________

Cell Phone Number:________________________________________

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