Medical Release Form

Your Details

Name *

Phone Number *

Address *

City *

State *

Name of Parent (If under 18)

Zip Code *

Email *

Date of Birth (M/D/YY)

Traveling With A Missions Group?

Yes

Mission Group Name (if applicable)

Group Leader's Name (if applicable)

Emergency Contact Details

Contact Name *

Contact Phone Number *

Relationship *

(Husband/Wife; Parent; Child; Friend)

Your Physician in USA *

Physician's Phone Number *

Serving Details

I authorize the above named adult and above named missionary sponsor, if I am unable to do so, to consent to any necessary examination, anesthetic, medical diagnosis, surgery, or treatment and/or hospital care rendered to me under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine by the state or country in which they practice, during the duration of the trip identified above.

Medical Conditions *

Any medical conditions which those around you should know about in the event of an emergency? List here and also be sure to apprise your missionary sponsor: your group leader (if traveling with a group) before the trip. This is your responsibility.

Blood type

(if known)

Medical Insurance that would cover an emergency or injury in Honduras is strongly recommended. If you do not currently carry such coverage it can be obtained on a short term basis through I.M.G.’s Group Outreach Travel Plan. An I.M.G. Group Outreach Travel enrollment form can be obtained at www.gomissiontrip.com or by contacting the Cornerstone office.

Insurance Verification *

I have my own insurance and will upload a photo copy in the field below and/or

I have purchased coverage through I.M.G or

I understand that the countryside of Honduras is a potentially dangerous place and that I &/or my dependants may be at risk for injury or illness @ Loma de Luz. I understand that emergency medical services and/or evacuation services are limited. I have been informed of the advisability of obtaining catastrophic health care insurance including evacuation insurance and have decided against it. In the case of injury or need for evacuation I will bear the expenses entirely and will hold harmless Loma de Luz, A.P.A.H., and/or The Cornerstone Foundation.

Image of Insurance Card

Maximum file size: 419.43MB

By submitting this form I am stating that all information above is true, accurate and complete.

If you are human, leave this field blank.