Trinity Baptist Church, Norman Medical Release / Permission to Treat Form
Trip Location: ______________________ Trip Dates: __________________ Team Leader____________________________
Name: _____________________________ Gender: _____ SSN: ________________DOB_______________ Age: _________ Complete Address: ____________________________________________________________________________________
Home Phone: ______________________________________ Cell Phone____________________________
Parent/Guardian (if younger than 19 years )___________________________________________________
Provide the name/contact information of two individuals not traveling with you who may be contacted in the event of an emergency.
Name (s): _________________________________________ Name: ___________________________________________
Relationship to You: _________________________________ Relationship to You: ________________________________
Phone: ____________________________________________ Phone: ___________________________________________
Alt. Phone: _________________________________________ Alt. Phone: _______________________________________
Insurance Company: _________________________ Relationship: ________________ Policy #: ______ Group #: _______
Ins. Co. Address: ______________________________________________________Phone: __________________________
Primary Care Physician: ________________________________________________ Phone: __________________________
Do you have any allergies? _____ Yes _____ No If yes, explain: __________________________________________________
Have you had contact with contagious/infectious diseases within the last 4 weeks? _____ Yes _____ No
If yes, explain: _________________________________________________________________________________________
Do you have any special dietary restrictions? _____ Yes _____ No If yes explain ___________________________________
List any specific medical conditions requiring medical treatment and/or medication: _______________________________________ _____________________________________________________________
List all operations/serious injuries (include dates) within the past 5 years: _____________________________________________________________________________________________________
List ALL medication taken on a regular basis: _____________________________________________________________________________________________________
What type of pain medication may be given if necessary _______________________________________________________
I hereby give permission to medical personnel selected by my team leader or his/her designee (hereafter the Authorized Agent) to order X-rays, routine tests, and treatment for me. In the event of an emergency and neither my primary nor secondary contact can be reached, I hereby give permission to the physician selected by the Authorized Agent to secure proper treatment, hospitalize, order injections and/or anesthesia, and/or authorize surgery for me. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release BH, its employees or agents, and in country contacts from liability associated with participation in a mission trip. I understand that if I do not have medical insurance, I will be responsible for any medical expenses in the event of a sickness or injury. I understand that there are risks involved in participating in a mission trip.
Signature: _____________________________________________ Date: _________________________ (Must be signed by a parent or guardian if under 19 years of age.)
The following is to be completed by the Notary Public witnessing the individual’s signature. The State of ______________________________ the County of ______________________________ Before me, a Notary Public, on this day personally appeared ______________________________ known to me (or proved to me on the oath of ______________________________) to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he executed the same for the purpose and consideration therein expressed. Given under my hand and the seal of the office this ________________ day of ___________________, A.D. ____________________.
Notary Public Signature ________________________________________________________________ My commission expires the _______________ day of ____________________, A.D. _______________.
Name: ____________________________________________ Relationship to You: _________________________________ Phone: ____________________________________________ Alt. Phone: _________________________________________ Policy Holder: ______________________________________
Trinity Baptist Church Release of Liability
In signing this form, I, _____________________________, agree not to hold Trinity Baptist Church, her officers, employees, or other agents liable for any injury, loss, damage, or accident that I might encounter while on a missions event/effort.
I realize and acknowledge that my participation on a mission trip to a foreign country includes risk and possible dangers. I am well aware that my travel to such a foreign country exposes me to such risks as accidents, disease, war, political unrest, injury from construction projects, and other calamities.
I hereby assume any such risks that might result from my participation in a midterm missions project, and I unconditionally agree to hold Trinity Baptist Church, its officers, employees, or other agents blameless for any liability concerning my personal health and wellbeing, or any liability for my personal property that might be lost, damaged, or stolen while on a short-term mission trip.
Signed: ____________________________________________________________________________________ Parent’s Signature (if under 19 years of age): _______________________________________________
And dated this ____________________ day of _____________________, 20_______.
The following is to be completed by the Notary Public witnessing the individual’s signature.
The State of ____________________________ the County of ____________________________ Before me, a Notary Public, on this day personally appeared _____________________________ known to me (or proved to me on the oath of _________________________________________) to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he executed the same for the purpose and consideration therein expressed. Given under my hand and the seal of the office this ________________ day of ___________________, A.D. _________.
Notary Public Signature _________________________________________________________ My commission expires the _______________ day of __________________, A.D. __________.