Medical Information & Waiver

Liability & Medical Treatment Release Form

"*" indicates required fields

Name*

First Middle Last

Please use the name that is on your passport.

Trip Dates (Depart)*

(Return)*

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

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*

Parent's Signature for Minors

Date

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

Due Date

Personal Physician’s name and phone number:*

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Medical Information & Waiver

Liability & Medical Treatment Release Form

Emergency Contacts

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