Kagyu Changchub Chuling

A center for the practice and study of Vajrayana Buddhism founded by His Eminence Kalu Rinpoche

First Aid and Emergency Medical Treatment

Version dated: March 19, 2004

I recognize that there may be occasions where I may be in need of first aid or emergency medical treatment as a result of an accident or illness. I hereby give permission for agents of KCC to seek and secure any medical treatment, including hospitalization, which may be deemed necessary and reasonable under the circumstances. I agree to pay all fees and costs arising from such action to obtain medical treatment. This permission for emergency medical treatment also includes minors under my control.

Dated: ____________________

Sign Name: __________________________________

Print name: __________________________________

Address:_________________________________________________ ________________________________________________________________

Emergency Contacts

Medical Doctor________________________

Phone _____________________

Name____________________________________ Relation_______________________

Home Phone__________________ Other phone___________________

Name____________________________________ Relation_______________________

Home Phone__________________ Other phone___________________

Medical History and Special Medical Needs ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________