Permission of Physician Form 2010

Please fill out this form or download and mail to us.

In order to protect all participants and the excavation project, we now require a physician's permission form, signed (digitally if possible) by a physician for each member of the team. The work of excavation is demanding and requires good health, physical stamina, agility and mobility. Please have your family physician complete this secure form and sign and submit it. The form can also be downloaded in PDF format, printed, signed by the physician and faxed if necessary -- 951 785-2199. DEADLINE - 15 May 2010

Full Name:
Email:
Address:
Telephone Number:

Purpose of the physician's form: The above applicant wishes to participate in an archaeological expedition in the country of Jordan. Working conditions are hot, dusty and physically demanding. The purpose of this form is to document that in your judgment, this applicant does not have any physical or emotional problems or issues that would make it impossible to participate fully in the dig activities.

Condition	No / Yes	Details
To the best of your knowledge, does the above applicant have any of the following?
Allergies
Heart Disease
Diabetes
GI Problems
Arthritis
Back Problems

Any other serious medical or emotional conditions?

Current medications:

Signature (enter your full name):

To the best of my knowledge, the above-named applicant is able to participate in the rigors of an archaeological expedition, please check here: your initials and today's date