THE CORNERStONE FOUNDATION

"...the stone which the builders rejected has become the cornerstone;" Mt. 21:42

18384 West Lake Drive - Saucier, MS 39574

Ph. (toll free) 877 277 8663 Ph./FAX 228-328-1579

e-mail: cornerstone@ametro.net -- web site: crstone.org

MEDICAL RELEASE FORM

Your Name (please print)________________________________________________

Address______________________________________________________________

City_____________________________ State______ Zip______________________

Phone____________________________ Email address _______________________

Name of Emergency Contact(s) _____________________________ Phone No.______________

Relationship (e.g. husband/wife; parent; child; friend) __________________________________

Participant’s Physician in USA _________________________ Phone (_____)______________

You will be serving in Honduras:

Departure Date from USA___________________ Return Date to USA____________

Location: ____Hospital Loma de Luz ____Other? (specify)______________________

I, (participant)__________________________ authorize (another adult on trip if traveling in a group and your missionary sponsor) _________________________ and __________________________, 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 Insurance Provider_____________________ Phone (_____)_______________

Policy Number_______________________________

Allergies and Medications: _________________________________________________

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. ______________________________________

____________________________________________________________________

*Medical Insurance that would cover an emergency or injury in Honduras is required. 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.

_______ I have my own insurance (a copy of my insurance card is attached) and/or

_______ I have purchased coverage through I.M.G.

Signature_________________________________________ Date__________________

Signature of Parent (for youth under 18)______________________________ Date ______________

Mission group name (if appropriate/coming with a group) ___________________

Group Leader______________________________________________________________