October 20, 2009
Action Plan: Papering/Medical Release
Medical Release Form
Numbers 10:29 - "If you come with us, we will share with you whatever good things the Lord gives us."
Doctor’s Name, Phone, Address:
Allergies (Food, Medications, Bees/Wasps, etc.):
Medical Insurance: Company, Agent, Policy, Phone, Address
Emergency Room Contact: Name, Relationship, Phone
I, _____________ (volunteer’s signature), authorize ________________________ (team leader) to consent to any necessary examination, anesthetic, medical diagnosis, surgery, or treatment and/or hospital care rendered under the general supervision and on the advice of any physician or surgeon licensed to practice medicine by the state in which they practice, during the duration of the trip identified above and further authorize the release of medical information from my personal medical records for the following purpose: ___________________, but I do not give permission for any other use or re-disclosure of this information.
Complete only if team member is under age 21:
Parent/Guardian: Name, Phone, Address
I hereby give my permission for __________________ (name of team member) to be treated by competent medical personnel as a result of any accident or medical emergency while involved in the GITC mission trip.
Signature, Date, Printed Name, Relationship to Youth above
Official form may be found at www.getinthecar.org.
Posted by jaselin at October 20, 2009 11:59 AM