Medical Information And Release Form printable pdf download

United Methodist Volunteers in Mission

Phone: 205.453.9480

Southeastern Jurisdiction Office of Coordination

Fax: 205.453.9481

100 Centerview Drive, Suite 210

Email:

Birmingham, AL 35216

Medical Information and Release Form

Team Leader: Please keep the original copy

Name ___________________________ _______

Work Phone __________________________

Address _________________________________

Home Phone __________________________

__________________________________

Fax __________________________________

Date of last physical examination ________________

Email ________________________________

Country ___________________________________

Departure Date ______/_______/________

Location __________________________________

Return Date

______/_______/________

Project Name ______________________________

Team Leader_________________________

I, ___________________________________ authorize ______________________________

(participant)

(adult on trip)

if I am unable to do so, to consent to any necessary examination, anesthetic, medical diagnosis, surgery, or treatment

and/or hospital care rendered to me under the general or special supervision and on the advice of any physician and

surgeon licensed to practice medicine by the state or country in which they practice, during the duration of the trip

identified above.

Participant’s Physician ____________________________

Phone (

) _________________

Medical Insurance Provider ________________________

Phone (

) _________________

Policy Number __________________________________

Allergies and Medications _________________________________________________________________________

______________________________________________________________________________________________

Physical disabilities and health problems (indicate whether you have special needs regarding sleeping

accommodations, meals, etc.) ______________________________________________________________________

______________________________________________________________________________________________

Signature of Participant_____________________________________ Date _____/_____/_______

Signature of Parent_________________________________________Date _____/_____/_______

(for youth under 18)

Notarization of Medical Release Form

STATE OF___________________________ PARISH OR COUNTY OF ______________________________

On this ______ day of _________________, _________ (year), before me personally appeared ___________________ to me known

to be the same person described in and who executed the within instrument, and who acknowledged the same to be the free act and

deed thereof.

Notary Public __________________________________________ County/Parish __________________________________

State of ______________________________________ My Commission Expires ___________________________________

Medical Information And Release Form

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