Medical Release Form

 

I        will be participating in a missions trip to

            first name                        last name                                                                                                                  country

  taking place    led by staff members and leadership of New Hope Worship Center.

 

New Hope staff and trip leaders have my full consent to obtain medical care for me in the event that I require medical attention for emergency and non-emergency situations. Furthermore, consent/permission is hereby given to staff and leadership on this trip to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery (under recommendation of qualified medical personel).

 

I understand that New Hope Worship Center does not carry accident or medical insurance on participating trip attendees. I agree that my insurance company will be used for such medical care expenses and I am aware that I may be billed by the medical provider for any medical treatment expenses not covered by my insurance. I understand that if I do not have medical insurance coverage that I am responsible for the payment of any medical bills.

 

 By checking this box, I agree to the above medical terms and conditions for the missions trip I am applying for.

Full Name:   Date:   

 

 

 The following is a list of all medical conditions that I suffer from:

(Please include all allergies. If none please write "N/A")

 

The following is a list of medications I am currently taking:

(If none please write "N/A")

 

The following is a list of all medications that I am allergic to:

(If none please write "N/A")

 

 

In case of emergency, please contact:

1. Full Name:

    Phone 1:      -  -    Cell    Home     Work

    Phone 2:      -  -    Cell    Home     Work

    Relationship:

 

2. Full Name: 

    Phone 1:      -  -   Cell    Home     Work

    Phone 2:      -  -   Cell    Home     Work

   Relationship:

 

 

I am currently insured by the following medical insurance company:

(If you are uninsured please write "N/A" in the following fields ) 

 

Policy #:

 

Policy Holder:

 

Physician Name:

 

Physician Phone #:

 

 

 New Hope Worship Center staff or other leaders of the trip have my full consent to obtain medical care for me in the event of an emergency.