Microsoft word - application_v2.docx

Insurance Information: If you do not have insurance, please contact DeLise Kroening Insurance Company: _______________________________________ Policy Number: ___________________________________________ I certify the information on this form is correct and I H In an emergency I give my permission to a licensed physician to hospitalize, anesthetize, or perform surgery as needed. Signature: ________________________________________________ Date: ______________________ Medical Information Date of last tetanus shot (must be within last 10 years) _______________________ Check the appropriate blank if you have ever had any of the following apply to you:* ________ Allergies (including drug) Name: __________________________________________________________________________________ Address: ___________________________________________________________________________ City: __________________________________ State: ________ Zip Code: ____________________ Phone #: ____________________________ Relationship: ______________________________________________________________________ * DES _______________________________________________________________________________________ _______________________________________________________________________________________ Youth Participation/Guardian Release In consideration of being allowed to participate in the trip sponsored by Moody Radio and Cornerstone Ministries I hereby release Moody Radio and Cornerstone Ministries from all claims and liabilities of any kind, whether known or unknown, which arise from or are connected in any way with my participation or the participation of any member of my family including my spouse or minor child, in the trip. I recognize that the conditions in some of the places to which I, my spouse, or my child will travel are not of the same standard as the conditions to which I am accustomed. I realize further that there are certain health risks as well as other risks to personnel and property, and I enter into participation in this trip and agree to the participation of my spouse or minor child with knowledge of those risks. If for any reason my child is unable to complete the planned stay on the mission trip, I assume full responsibility for expenses incurred for my child’s return home. In the event of an emergency, I hereby authorize a leader of this trip, as an agent for me or my spouse or my child to consent to: any x-ray examination; medical, dental or surgical diagnosis; treatments; hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state or country where services are rendered, either at a doctor’s office or in a hospital. I expect my family to be contacted as soon as possible. I certify that I am of lawful age and competent to sign this Release, and have done so voluntarily. I understand that this document constitutes a full and complete waiver of all possible claims for any act of omission, including claims for negligence regarding injury or property damages, arising out of my participation in the trip. I understand that this release applies to, covers, and includes unknown, unforeseen, unanticipated, and unsuspected damages, losses, or liabilities and the consequences thereof, which result from the matters hereinbefore inferred to as well as those now disclosed and known to exist. The provisions of any state, federal, local, territorial law or statute providing in substance that releases shall not extend to claims or damages which are known or unsuspected to exist at the time are hereby expressly waived by me. Signature: ______________________________________________________________________________________________________ Printed Name: _________________________________________________________________________________________________

Source: http://www.moodyradioflorida.fm/uploadedFiles/Radio_-_WKES/Library/PDF/Navajo2013-Application_v2.pdf