Medical Information & Waiver

Liability & Medical Treatment Release Form

Name*
First Middle Last
Please use the name that is on your passport.
Trip Dates (Depart)*
Date Format: MM slash DD slash YYYY
(Return)*
Date Format: MM slash DD slash YYYY
I do certify that I will be traveling to Honduras, Central America, to participate in the Tegucigalpa and San Matias, LTCare Ministries, Ministries of Divine Mercy (MDM Honduras) & Operation New Life outreach. I hereby release LTCare Ministries, Ministries of Divine Mercy (MDM Honduras), Operation New Life, DIME Hospital, and Hospital Escuela and their appointed agents, and any other hospital or ministry worksites, from any and all liability as a result of any accident, sickness or death that I may incur while participating in this outreach. Furthermore, I authorize the leadership of Love Truth Care Ministries, Ministries of Divine Mercy (MDM Honduras) & Operation New Life to take me to a doctor for medical treatment, emergency surgery and/or hospitalization should the need arise. I assume total responsibility for payment of all bills associated with the above-mentioned medical attention.
Insurance Company:*
Phone Number:*
Policy Number:*
Group Number:*
Note: U.S. Medical Insurance does NOT typically cover you outside of the U.S.A.
Is this travel insurance?*
- Yes
- No
Finally, should it be necessary for me to return to the United States for any reason prior to the established return dates, I assume total responsibility for payment of all associated transportation costs.
Participant's Signature*
As shown on passport.
Date*
Date Format: MM slash DD slash YYYY
Parent's Signature
For minors
Date
Date Format: MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Phone Number*
Email*
Emergency Contacts
Name*
First Last
Relationship*
Phone Number*
Name*
First Last
Relationship*
Phone Number*
Are you currently under a doctor’s care for any medical condition(s)? Please list:
Please list all prescription medications you are taking:
Name Dosage Condition/ Reason
What is your blood type?*
Are you pregnant?*
- Yes
- No
Due Date
Date Format: MM slash DD slash YYYY
Personal Physician’s name and phone number:*

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