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.
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.
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: ___________________
E-Mail: ________________________________ Phone: _____________________ Date of Birth: _______________
Insurance Carrier: ___________________________________________ Policy #: ___________________________
Physician’s Name: ________________________________________________ Phone: _______________________
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:
Home Phone: ___________________ Cell Phone: ___________________ Work Phone: __________________
Other person(s) to contact if above name is not available:
Name: ____________________________________ Phone: __________________________