BH Medical Release / Permission to Treat Form

Trip Location: ______Trip Dates: ______Team Leader: ______

Name: ______Gender: _____SSN: ______DOB: ______Age: ______

Complete Address: ______

Home Phone: ______Cell Phone: ______

Parent/Guardian (if younger than 19 years old): ______

Provide the name/contact information of two individuals not traveling with you who may be contacted in the event of an emergency.

Name: ______Name: ______

Relationship to You: ______Relationship to You: ______

Phone: ______Phone: ______

Alt. Phone: ______Alt. Phone: ______

Insurance Company: ______Policy Holder:______Relationship: ______Policy #: ______Group #: ______

Ins. Co. Address: ______Phone: ______

Primary Care Physician: ______Phone: ______

Physician Address: ______

Do you have any allergies? _____ Yes _____ NoIf yes, explain: ______

______

Have you had contact with contagious/infectious diseases within the last 4 weeks? _____ Yes _____ NoIf yes, explain: ______

______

Do you have any special dietary restrictions? _____ Yes _____ NoIf yes, explain: ______

______

List any specific medical conditions requiring medical treatment and/or medication: ______

List all operations/serious injuries (include dates) within the past 5 years: ______

______

List ALL medication taken on a regular basis: ______

______

What type of pain medication may be given if necessary? ______

I hereby give permission to medical personnel selected by my team leader or his/her designee (hereafter the Authorized Agent) to order X-rays, routine tests, and treatment for me. In the event of an emergency and neither my primary nor secondary contact can be reached, I hereby give permission to the physician selected by the Authorized Agent to secure proper treatment, hospitalize, order injections and/or anesthesia, and/or authorize surgery for me. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release BH, its employees or agents, and in country contacts from liability associated with participation in a mission trip. I understand that if I do not have medical insurance, I will be responsible for any medical expenses in the event of a sickness or injury. I understand that there are risks involved in participating in a mission trip.

Signature: ______Date: ______

(Must be signed by a parent or guardian if under 19 years of age.)

The following is to be completed by the Notary Public witnessing the individual’s signature.

The State of______the County of ______Before me, a Notary Public, on this day personally appeared ______known to me (or proved to me on the oath of ______) to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he executed the same for the purpose and consideration therein expressed. Given under my hand and the seal of the office this ______day of ______, A.D. ______.

Notary Public Signature ______

My commission expires the ______day of ______, A.D. ______.

The Church at Brook Hills

Release of Liability

In signing this form, I, ______, agree not to hold The Church at Brook Hills (BH), her officers, employees, or other agents liable for any injury, loss, damage, or accident that I might encounter while on a missions event/effort.

I realize and acknowledge that my participation on a mission trip to a foreign country includes risk and possible dangers. I am well aware that my travel to such a foreign country exposes me to such risks as accidents, disease, war, political unrest, injury from construction projects, and other calamities.

I hereby assume any such risks that might result from my participation in a mid-term missions project, and I unconditionally agree to hold The Church at Brook Hills (BH), its officers, employees, or other agents blameless for any liability concerning my personal health and wellbeing, or any liability for my personal property that might be lost, damaged, or stolen while on a short-term mission trip.

Signed: ______

*All Parent’s/Guardian’s with custody must sign.

Parent’s Signature (if under 19 years of age): ______

And dated this ______day of ______, 20______.

The following is to be completed by the Notary Public witnessing the individual’s signature.

The State of ______the County of ______Before me, a Notary Public, on this day personally appeared ______known to me (or proved to me on the oath of ______) to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he executed the same for the purpose and consideration therein expressed. Given under my hand and the seal of the office this ______day of ______, A.D. ______.

Notary Public Signature ______

My commission expires the ______day of ______, A.D. ______.

International Travel Permission Form

As the parent/guardian of the minor listed below, I give my permission for them to travel under the supervision of

______(Trip Team Leader)

Thus, I am aware of my child’s travel outside of the United States, and have completed the required release of liability and medical release forms.

Trip Location: ______Date of Trip: ______

Child’s Name: ______

*All Parent’s/Guardian’s with custody must sign.

Parent’s/Guardian’s Name: ______

Parent’s/Guardian’s Signature: ______Date: ______

Parent’s/Guardian’s Name: ______

Parent’s/Guardian’s Signature: ______Date: ______

The following is to be completed by the Notary Public witnessing the individual’s signature.

The State of ______the County of ______Before me, a Notary Public, on this day personally appeared ______known to me (or proved to me on the oath of ______) to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he executed the same for the purpose and consideration therein expressed. Given under my hand and the seal of the office this ______day of ______, A.D. ______.

Notary Public Signature ______

My commission expires the ______day of ______, A.D. ______.

Application Checklist

NOTE: Please submit the following materials to the Global-Disciple Making Team at The Church at Brook Hills by the

REGISTRATION DEADLINE for your trip. These materials can be submitted at the Global Kiosk on Sundays, at the church office Monday-Friday 8am to 5pm, or thru your team leader. Your application will not be considered complete until all of these materials are turned in to the Global Disciple-Making Team.

Top of Form

  • Completed Application

Bottom of Form

  • Completed Medical Release Form with Notary
  • Completed Liability Waiver with Notary
  • Completed International Travel Permission Form with Notary
  • $200 Non-refundable Deposit
  • 1 Color copy of your Passport
  • 2 passport size photos for trips going to India, Nepal,East Asia ONLY (These are free at the Inverness UPS Store if you acknowledge you are going on a Brook Hills mission trip.)
  • A copy of you proof of residency for trips going to India ONLY (This can include a copy of your driver’s license if the address on your license matches your current residence. If not, you will need to produce a utility bill for this requirement.)