STW Medical Consent

Name*

First NameLast Name

Birth Date*

Date

Trip Destination(s)*

Trip Dates*

Medical Insurance Company*

Policy Number*

Insurance Company Phone Number

Area CodePhone Number

Medical Information

Please asnwer the following questions as truthfully as possible as it's vital that we know ahead of time of any potential health concerns that could arise during the trip.

1. Please list any major health problems or surgeries you've had in the past two years.*

2. Please describe any physical conditions which could limit your ability to participate in certain activities of this trip?*

3. Please list any prescribed medications you are currently taking and the dosage.*

4. Please list any allergies you have (to medication, food, etc).*

5. Please list any special dietary needs you have.*

U.S. Emergency Contact Information

In case of an emergency, who should we contact?*

First NameLast Name

Relationship to you?*

Phone Number*

Area CodePhone Number

Email Address*

Medical Consent

This is a consent for medical treatment, should you be unable to give consent for any reason.

I wish to participate on a Short Term Team with Overlake Christian Church. We will be traveling to and residing in the destination(s) listed above. Whereas circumstances occur that should result in in my need for medical care or treatment, and I am unable to give my verbal consent, I authorize the Overlake Christian Church Trip Leader(s) to give such permissions on my behalf. The medical/dental treatment and care includes, but is not limited to examination, diagnostic testing, x-rays and scans, anesthesia, surgery, or other procedures deemed necessary for my medical well being for the duration of the mission trip. This consent shall also include permission to administer any over the counter medications including, but not limited to Tylenol, Advil and allergy medications for treatment and care on my behalf. *

Signature

Date

I understand that although great effort is made to provide adequate housing and suitable in country conditions, some of Overlake Christian Church's Short Term Teams can be strenuous and stressful. Most trips will include a long plane, train, and/or bus rides, the need to carry your own luggage, exposure to some extreme temperatures, and walking some distances. I recognize that all of these factors can aggravate certain health conditions and that it is very important that I communicate any medical concerns or limitations to my team leader prior to leaving the country. In addition, should my team leader feel concerned about my ability to travel and participate in this trip due to health concerns, then I give permission for my team leader to request a medical clearance for travel from my doctor. *

Signature

Date

I understand that international medical insurance is a requirement for me to go on an Overlake Christian Church trip. I understand that Overlake Christian Church provides international medical insurance that covers medical issues that I may incur on the trip from the time I leave the U.S. until the time I return to the U.S., but that I may obtain my own international medical coverage if I choose. I also understand that many of the medical facilities available to us in the countries we travel to, may not provide the care we are accustomed to in the United States. *

Signature

Date