Medical Evaluation Form printable pdf download

MEDICAL EVALUATION FORM/DISCLAIMER

Medical Ministry International serves in a variety of locations around the world and our focus is to serve the Poor. It is

with intention that we seek confirmation that our Volunteers will be able to fulfill their roles in somewhat limited and

difficult environments when necessary.

I have known this patient for the past _________________ (years/months)

This Participant is presently in good physical and mental health and to my knowledge, has no chronic or long-term

health problems that could pose a risk to being able to participate on a Project Team.

While working with the Project Team, the Participant may be exposed to long days, challenging conditions, etc. Are

there any medical issues that could limit the participant from being able to participate and cause significant disruption

to the team?

Please check here and attach a description of any issues

___________

Date: ________________________

Physician: _______________________________________

(Signature)

Name of Physician: _______________________________________Phone #: _______________

(Please Print)

Address of Physician: ____________________________________________________________

Disclaimer for Participation: MMI reserves the right to deny or remove a participant from MMI initiatives for any reason if it

is determined that the individual or group’s behavior, personality, physical limitations, etc., preclude the team from

accomplishing its designated goals. MMI is an organization that follows the example of Jesus and any violation of moral or

ethical standards can result in immediate dismissal. The participant will be liable for all additional costs incurred or claims from

third parties, and MMI will not be liable for any compensation or damages resulting from said issues.

ALL PARTICIPANTS ARE REQUIRED TO RESEARCH AND DETERMINE ANY NECESSARY IMMUNIZATIONS OR

MEDICATIONS FOR THE AREA WHERE THEY ARE SERVING.

______________________________________

_____________________

Volunteer Signature

Date

Printed name___________________________

Medical Evaluation Form