Medical and Permission Form
Parent / Guardian Permission, Release, and Consent for Medical Treatment
Permission: As the parent or legal guardian of _______________________________________________, I give permission for him/her to participate in the Spencerville Church - Seventh-day Adventist, Youth Mission Trip to the Dominican Republic, March 25 – April 5, 2009. I understand that transportation to and during this mission trip will include airplanes, buses, cars and vans.
Conditions: I agree to assume all financial responsibility resulting from my child’s behavior or actions requiring additional expenses; including but not limited to damages to the property of others and any and all additional costs should it become necessary to send my child/children home early. I understand this will include my child's ticket home, the cost of a chaperone's ticket to return you child AND the cost of a ticket returning the chaperone to the Dominican Republic so that the chaperone can continue the mission trip. It is understood, should medical care be required, our family’s insurance is to be the primary insurance coverage and while additional travel insurance is included in the price of the trip, it is secondary insurance, subordinate to our regular medical coverage.
Privacy Release: I hereby authorize any medical practitioner, hospital, facility, insurance company or any other person or entity that has medical records or knowledge of medical records of the undersigned or my above listed dependent, to release such information to or to discuss said information with, medical practitioners, hospitals, facilities or insurance company providing treatment during the above listed trip. The privacy of this information will be guarded by the Spencerville Church Mission Team as required by law.
Release and Consent for Treatment: I hereby release Spencerville Church, it’s staff and sponsors, from responsibility and liability for any injury or illness that my child may sustain during this activity. I hereby authorize an adult leader of this activity, as agent for me, to consent to any X-ray examination; medical, dental or surgical diagnosis; treatment; dispensing of medication including non-prescription medication; and hospital care advised and supervised by a physician, surgeon, nurse or dentist (as appropriate) licensed to practice either in the United States or in the country where services are rendered. The information provided below is detailed and complete, it maybe fully relied on in the treatment of my child. In the event of an emergency, I expect to be contacted as soon as possible. I have read this form, I understand that it waives certain rights and I am signing it voluntarily.
Allergies including food allergies __________________________________________ Medications - including as needed &
over the counter items (allergy, inhaler, bee sting items) ______________________________________________________
____________________________________Recent Illnesses or Injuries_____________________________________
Medical conditions or physical handicaps______________________________________________________________
Other information we should know including surgeries that might be relevant to mission service while in Belize. (Please remember the youth will be performing emotional, physical, and spiritual labors on this trip.)
Physician ___________________________________________ Physicians Phone # __________________________
Medical Insurance Co_____________________________________ Member’s Name__________________________
Group # __________________ Group Name ______________________________Policy # _____________________
Signature of Parent or Legal Guardian Printed Name
Signature and Seal of Notary Public