Cuirim Outreach Information Form

We are glad you have decided to join us.  Our center in Mexico, called Cuirim (KEER-um) House, is located at 270 Chatinos in the Colosio neighborhood of southern Nogales.   Whether you are spending a day or a week with us, we hope you enjoy your stay.  Due to the nature of our work and the fact that we are crossing an international border, we have a few administrative details to cover before you come down.  Please fill out this page and give it to your leader before you come.  For those staying for more than 3 days, we require a color copy of your photo identification.

Name of participant: _____________________________  

I, for myself and any minor children for whom I am parent or guardian to hereby release, acquit and forgive Cuirim Outreach Inc, its principals, directors, employees and volunteers from any and all injury and damage to me or said minor as a result of my/our participation in the activities of Cuirim Outreach.

I, for myself and any minor children from whom I am parent or legal guardian and for my/our heirs, personal representatives or assigns, also expressly waive any claim, lawsuit, complaint, charge, or cause of action against Cuirim Outreach Inc., its principals, directors, employees, volunteers for any and all injury or damage to me or any such minor children and other persons as a result of my/our participation in the programs of Cuirim Outreach.

Do you have any health issues we should know about?

Do you have any allergies to medications, foods, insects or plants?

Are you currently taking any medications?

Physician ______________________  Address & #___________________________________________

Contact person and phone # _______________________________________________________

(IMPORTANT IF YOUR CHILD IS UNDER 18)  I give my child permission to enter Mexico during the following period of time: ___________________.

  Signature ________________________________

  Please print your name _______________________

(Optional)  If you would like to receive the Cuirim Outreach monthly mailing, please give us your mailing address  ____________________________________________________________________________