WMI Trip Medical Form

Medical Information

* Name of Trip Participant:

Emergency Contact #1:

Relationship to Traveler:

Cell Phone:

E-mail:

Emergency Contact #2:

Relationship to Traveler:

Cell Phone:

E-mail:

Describe any Medical Conditions including Allergies, Dietary Restrictions, Medications, etc.

Medical Insurance Company and Address:

Policy Number:

Phone:

Coverage for Treatment outside of the U.S.?

Yes

*If you are not covered for treatment outside the U.S., you MUST purchase medical travel insurance to assist with such costs in the event of an emergency. Plans for individuals normally cost $1-$2 per day. Visit http://www.missionaryhealth.net/shortterm/ for more information.

Medical Release

The undersigned acknowledges that he or she shall be liable for and agrees to pay all costs and expenses incurred for medical and dental services rendered to the undersigned while on this mission trip and for any illness or injury arising during this mission trip.

Should it be necessary to return home due to medical reasons or otherwise, the undersigned will pay all transportation costs (which in the event of medical evacuation flight may be substantial). (Check with your group leader as some groups buy insurance as a group and include it in the cost of the trip.)

Please type your full name for your signature:

Date:

Waiver of Liability/Assumption of Risk

I am aware that a mission trip such as the one that I am undertaking involves hazardous activities in a distant and remote area of the world with a risk of illness, injury or death by disease, illness and or intentional or unintentional actions by others including criminal conduct. I am also aware that medical services or facilities and police or military protection services may not be readily available or accessible during some or all of the time during which I am participating on the trip. I am willing to accept the risks and uncertainty of this mission trip. I HEREBY ACCEPT AND ASSUME FULL RESPONSIBILITY FOR ANY AND ALL RISKS OF ILLNESS, INJURY OR DEATH ARISING FROM THE NEGLIGENCE (BUT NOT THE RECKLESS, WILLFUL, FRAUDULENT OR INTENTIONAL CONDUCT) OF THE MISSION TRIP LEADERS, OTHER TRIP PARTICIPANTS, THE OFFICERS AND EMPLOYEES OF ANY CHURCH, SEMINARY OR OTHER HOST ORGANIZATION THAT THE MISSION TRIP IS ASSISTING. I understand that by assuming these risks, I am giving up rights that I, or my estate, would otherwise have to bring a legal action to recover monetary damages in the event that I should be injured or killed or become ill.

Nothing in the paragraph immediately above shall be construed to diminish any right or action that I might have against any common carrier.

For good and valid consideration, I execute and deliver this agreement for cross-cultural mission participants. I have carefully read this document and have had an opportunity to have my questions answered. I am aware it constitutes a waiver and release of significant legal rights that I would otherwise have, and my execution of this Agreement is made voluntarily.

IN WITNESS WHEREOF, I have set my hand and legal seal the date indicated below.

Please type your full name for your signature:

Date:

Trip Destination:

Travel Dates:

Declaration of Witness:

I certify that (travelers name) acknowledged in my presence that he/she fully understood the meaning and consequences of the foregoing Agreement and signed it in my presence.

Travelers Name:

Witness, please type your full name for your signature:

Date:

Witness' name and address:

Trip Photo Release

I grant to WMI, its representatives and employees the right to take photographs of me and my property in connection with this trip. I authorize WMI, its assignee and transferees to copyright, use and publish the same in print and/or electronically.

I agree that WMI may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Yes

Please type your full name for your signature:

* required