Mission Trip Application and Medical Release Form

Full Name (as it appears on passport)

First NameMiddle InitialLast Name

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

How Many Children Will Be Traveling With You?

If Your Children Will Be Traveling With You, Please List Their Names and Ages

What Dates Will You Be Visiting Maison? What Team/Group Will You Be Traveling With To Maison?

How did you hear about FHG?

Have you ever been on a Mission Trip before?

If Yes, What Country/Year?

Please list any Gifts or Talents you have that you would like to share or use during your trip:

In what areas would you most like to serve while in Haiti?

Please share with us some thoughts and insight about your spiritual journey.

I have read and understand the FHG/MED Volunteer Code of Conduct

I have read and understood the Mission Travel Information Packet provided by the Mission Coordinator or my team leader.

Insurance Provider

Group Name

ID #

Will your insurance cover you out of the country?

Primary Physician

First NameLast Name

Phone Number of Primary Physician

Area CodePhone Number

Primary Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please list any medical conditions or limitations you may have.

Please list any allergies you may have.

Please list any medications you will be taking while on your trip.

Please list your immunizations and dates

Emergency Contact 1

First NameLast Name

Phone Number

Area CodePhone Number

Relationship to Applicant

Emergency Contact 2

First NameLast Name

Phone Number

Area CodePhone Number

Relationship to Applicant

In an emergency I give my permission to a licensed physician to hospitalize, anesthetize, or perform surgery on me. I understand that every effort will be made to inform my emergency contact before these actions are taken.

On behalf of Myself/My child, I further authorize For His Glory to: release any and all other medical information or records to any party deemed necessary by FHG, Its Agents, Servants, Employees; Assigned for providing medical treatment to Myself, My Child, or to members of Mission Group; Insure proper placement of Myself/ My Child in such group.

I hereby release and agree to indemnify FHG, Its Agents, Servants, Employees and Assigns for any and all damages, liability or costs resulting from the authorizing of medical treatment on My/My Child's under the terms of this consent. I further hold FHG harmless from any and all costs, damages or expenses incurred by FHG as a result of any claim or action filed by any party alleging damages incurred as a result of any medical treatment provided or authorized for treatment provided.

I am aware that serious illness or injury may occur on a mission trip and that such injury or illness may result in incurring costs, expenses, and any damage for which I am solely responsible including, but not limited to, return of myself or my child by air ambulance or other extraordinary means. I also understand that mission trips may be associated with risks of bodily harm, death, and/or damage to or loss of personal possessions resulting from, without limitation, inclement weather, transportation accident, or terrorism. On behalf of myself or my heirs, (and participant, if participant is under 18). I assume all such risks, whether foreseen or unforseen by FHG or Myself.

I hereby release and hold harmless FHG, Its Officers, Employees, Agents, and Representative/Volunteers from all liability for personal injury, including death, as well as all property damage or loss arising out of participation in this trip. I understand that this release and indemnification release liability for the conduct of FHG and Its Agents, Servants, Employees, or Assigns, even if such conduct is negligent.

Yes/No

I also give FHG the right to use my/ my child's picture, voice, and/or testimony in any form of promotional or advertising material.

Waiver of Foreign Travel trip Insurance: I understand that FHG strongly recommends the purchase of foreign travel trip insurance. I have read all of the materials presented in this application and travel release for and choose to not obtain such insurance.

Authorization: I have read and understand the above information.The information that I have given FHG is accurate and true to the best of my knowledge. (if under 18 a parent/legal guardian must sign this form)

I am over the age 18. If not, a parent/guardian must sign.

Date

MonthDayYear

Signature

Mission Trip Application and Medical Release Form

Medical Release and Insurance Information