Hábitat
para la Humanidad--Costa Rica
Hábitat
para la Humanidad--Costa Rica
Statement of Health Insurance, Waiver for Minors, Emergency Contact
Health Insurance
Date _________________________
I, ____________________________________, assure Habitat for Humanity-Costa Rica
that I have health insurance which covers me internationally while I am in Costa
Rica, traveling there or working on a construction site. I agree that I will
not hold Habitat for Humanity-Cost Rica liable for injuries incurred while in
Costa Rica.
Insurer (name of company):
Policy Number #_______________________________________________________________________________
Emergency contact number for medical reimbursement approval: _________________________________________
Signed ___________________________________________ Date _______________________________________
Emergency contact
If an emergency should occur while you are in Costa Rica, please list two people with whom we may communicate:
Name____________________________________phone_________________________relationship________________
Name____________________________________phone_________________________relationship________________
Minors and their guardian need only complete the below portion
of this waiver
*****************************************************************************************************
Minor consent
I, parent/guardian of brigade member _______________________________, do give my permission for him/her to participate in the construction of houses with Habitat for Humanity-Costa Rica. I agree that I will not hold Habitat for Humanity-Cost Rica liable for injuries incurred while in Costa Rica, and have completed the information on health insurance and emergency contacts listed above.
Signed _________________________________________ parent/guardian
of ___________________________________
(please print)
Date _____________________________
Notarized by:
Date: