North Central Baptist Association

Mission Trip - Adult

 

RELEASE, HOLD HARMLESS AND INDEMNITY, AND MEDICAL AUTHORIZATION FOR ADULT PARTICIPANTS

 

Release, Hold Harmless and Indemnity

 

I, the undersigned, acknowledge that participating in the NCBA Mission Trip to ___________ (“mission trip”) involves certain risks and that injury, death or other harm including damage to property could occur to me (“injuries”).  By participating in the Mission Trip, I hereby assume full responsibility for the risk of injuries, whether caused by negligence or otherwise.  I, on my own behalf and on behalf of my heirs, successors, assigns, executors and administrators, hereby RELEASE AND HOLD HARMLESS AND AGREE TO INDEMNIFY North Central Baptist Association of North Central Louisiana and its staff, volunteer leaders, employees, trustees, Executive Board members, churches, ministry and church leadership (“NCBA”) from and against any and all liability, claims, damages, causes of action, loss, costs and expenses (including, without limitation, attorney fees) for injuries arising out of or connected with the mission trip, including traveling to and from the location(s) of the mission trip.

 

Medical Authorization

 

If, while participating in the mission trip, I require emergency medical treatment, I hereby give my consent for any emergency medical care to be rendered as may be deemed necessary by any duly licensed physician or dentist.  I hereby give my permission to NCBA to obtain the emergency medical treatment at any hospital, clinic or other health care provider as may be deemed appropriate.  In these circumstances, I hereby request and authorize any duly licensed physicians, dentists and staff, or other licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment as may be necessary, including but not limited to medical transport, hospital tests, injections, anesthesia, surgery and administration of prescription drugs.  I agree to the release of any records necessary for treatment, referral billing, or insurance purposes from any Medical Contracts provided by NCBA.  I agree to assume full responsibility for medical expenses incurred as a result of such emergency medical treatment.

 

                                                                            

_________________________________________           

Signature 

                                                             

_________________________________________                       

Printed Name

Date:  ________________________________          

 

WITHOUT THIS FORM WITH YOU AND SIGNED YOU WILL NOT BE ALLOWED TO PARTICIPATE

 

A copy of the signed form shall be filed with the Associational office prior to trip departure.

 

 

 

 

 

 

MISSION TRIP RELEASE FORM – ADULT

 

Participant’s Name:  ___________________________________________________   Date: ___________________

Address:  _________________________________________________________________________________________

E-Mail: ________________________________ Phone: _____________________ Date of Birth: _______________

Insurance Carrier: ___________________________________________ Policy #: ___________________________

Physician’s Name: ________________________________________________  Phone: _______________________

 

Allergies: _________________________________________________________________________________________

Chronic Illnesses: ________________________________________________________________________________

Medication Currently Taking:_____________________________________________________________________

Physical Limitations (please list): _________________________________________________________________

Blood type: __________________            Are you subject to motion sickness? _____ yes  ____ no

Are you allergic to any medications (please list): _________________________________________________

 

PHOTO AND VIDEO PERMISSION

My permission is granted for NCBA to videotape or photograph me during mission trip events

and normal activities.  I understand these photos may be used in report and/or promotional materials.

Signature of Participant: _______________________________________________________

 

 

Emergency Contact Information: 

Name: ____________________________________________________________

Home Phone: ___________________ Cell Phone: ___________________ Work Phone: __________________

Other person(s) to contact if above name is not available: 

Name: ____________________________________       Phone: __________________________

             ____________________________________                    __________________________

             ____________________________________                    __________________________