Consentimiento Médico Informado

LA AURORA:

CIGAR INSTITUTE PARTICIPANTS CONFIDENTIAL MEDICAL CONSENT FORM

PLEASE COMPLETE ALL SECTIONS:
• Mark N/A if any section is not applicable to you.
• Toda Sección que no se complete requerirá seguimiento por escrito o por teléfono.
• La Ausencia de información solicitada puede limitar su participación en el evento.

INFORMACIÓN GENERAL Y DECLARACIÓN DE ACEPTACIÓN VOLUNTARIA PARA SU PARTICIPACIÓN.
Because the Cigar Institute program is taking place in Santiago, Dominican Republic (“Event”), we must receive this form duly and properly filled out and signed by you to have all relevant information from you in case you, for any reason, require medical assistance while participating at the Event.
If you have any question about your capability to participate in the Event, please contact the onsite organizers. All information contained in this document will remain confidential.

I, the undersigned:

Name
Country
Address
Phone
Sex
Date of birth
Height
Weight

I certify that I have read and understand the foregoing and hereby declare that I will answer truthfully and completely based on my current health condition the questions relating to my general heath and condition.
Please confirm if you suffer from any of the diseases/medical conditions listed below by marking an X to either YES or NO columns:

Neurological diseases: epilepsy, stroke, multiple sclerosis, head injury, defect of speech, severe headaches, meningitis, or any other disorder.?
Lung disease: asthma, rhinitis, sinusitis, persistent cough, emphysema, pneumonia, bronchitis, tuberculosis, frequent tonsillitis, or any other disease or disorder?
Heart disease: high or low blood pressure, arterial or venous thrombosis, aneurysms, varicose veins, palpitations, heart murmur, chest pain, angina, myocardial, and any other disorder and/or disease?
Gastrointestinal disease: gastroesophageal reflux, gastritis, peptic ulcer, diseases of the colon, duodenum, rectum, hemorrhoids, liver, gallbladder and pancreas, appendicitis, diverticulitis?
Genitourinary diseases of the bladder, kidneys, ureters, prostate, testicles, load, urinary tract infections, urinary incontinence, cysts, inguinal or umbilical hernia, nephritis, blood or pus in urine?
Diabetes, thyroid or other endocrine disorder. Anemia, or any other falcemia?
Do you have any disease, abnormality, are you receiving treatment, taking any kind of medication or pregnant?
Have you been in a hospital, clinic, sanatorium or other institution?
Have you received any blood transfusion?
Have you had positive results for a HIV test? Do you have AIDS or have been treated for any other immunological disease?
Do you have any medical condition not listed herein?
Yes, what type (use additional space)

I hereby consent to undergo any medical treatment, including but not limited to emergency treatment, hospitalization, anesthesia, or operations, which may be deemed necessary to treat any illness or injury that I may sustain during my participation in the Event. If I decline such treatment, I accept full responsibility for the medical outcome of my condition, regardless of the source of my injury or illness.
I represent and warrant that the information provided in this Confidential Medical Consent Form is complete and accurate to the best of my knowledge, and, if available, can be relied upon in the event the need for medical treatment may arise. Accordingly, I voluntarily accept and assume total responsibility for any adverse consequence that may arise to me or others from providing incorrect or incomplete information. In addition, I hereby release, indemnify and hold harmless (whichever may be appropriate) La Aurora, and their affiliates and all other persons and entities connected with the Event from any liability, illness, damage to property or death that may occur, directly or indirectly, to me or others, from the failure of this document to contain complete and accurate information.
For the purpose of this Declaration, the term "affiliate" shall mean any Person which is directly or indirectly Controlling, Controlled by, or under common Control with such party; "Control" means the power of Person or Persons to secure by means of the holding of shares or the possession of voting power in, or relation to, any other Person or by virtue of any power conferred by or under the articles of association or any regulation, agreement, arrangement, restriction or other document regulating or binding upon that Person, that the affairs of such Person are conducted in accordance with the wishes of that first-named Person or those first-named Persons; "Person" means any person, firm, partnership or corporation and any combination of any one or more of the foregoing whether or not having a separate legal identity.
I understand that this information constitutes personal data (including sensitive personal health data) and freely consent to the processing of such data by LA AURORA, S.A. and any of their nominated health professionals for the purposes of:

• Assessing my eligibility to participate in the Event; and,
• any medical treatment which I may require during my participation in the Event (together, the "Purposes").

I understand that my personal data (including sensitive personal health data) will be transferred to other countries which do not have the same standards of data protection which I enjoy in the country of my residence or citizenship for the Purposes and I freely consent to its transfer and processing for the Purposes as described herein.

IN CASE OF EMERGENCY CONTACT TO:

Contact
Relationship
Address
Phone (day)
Phone (night)
Date

Read and confirmed by Participant (Name and date must be legible and written in capital letters).

Please draw your signature with the mouse

Signature