Vim Medical And Liability Release Form

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VIM Medical and Liability Release Form
I___________________________________authorize_________________________________
(UMVIM participant)
(another adult on trip)
If I am unable to do so, to consent to any necessary examination, anesthetic, medical diagnosis, surgery
treatment and/or hospital care rendered to me under the general or special supervision and on the advice of
any physician or surgeon licensed to practice medicine by the state in which he/she practices, during the
duration of the trip identified below.
UMVIM Project:__________________________________ Dates ______________________
Home Physician______________________________ Phone (
)_____________________
Medical Insurance Provider ____________________ Phone (
)______________________
Policy Number _________________________ Group Number _________________________
Allergies ____________________________________________________________________
Medications _________________________________________________________________
Person In USA to contact in the event of an Emergency:
Name__________________________________________ Relationship _________________
Address______________________________________________ Phone (
)____________
Blood Type_____ Do you have? Diabetes ___Yes ___No
Seizures ____Yes ____No
Physical Limitation __________________________________________________________
___________________________________________________________________________
Other Medical Information ____________________________________________________
___________________________________________________________________________
Liability Release
The undersigned releases and agrees to hold harmless the General Board of Global Ministries of the United
Methodist Church, The UMVIM Board of the _____________ Jurisdiction of the United Methodist Church, the
____________ Annual Conference, and any related agency, conference, district, local church, member,
employee or agent, from any liability, injury, damages, loss, accidents, delay, or irregularity related to the
undersigned individual’s planned participation or involvement in the above named UMVIM Project. The
undersigned has been advised and understands that the project may involve unusual risks to participants.
Those risks may involve, among others, the following: Dangers resulting from disease; from civil warfare or
insurrection of the kind that we have seen in recent years in Somalia, Bosnia, Liberia; from post-warfare
hazards such as landmines; from geographic features such as high altitude, which may have a deleterious
effect on persons with heart conditions or respiratory diseases; from extreme heat and humidity with no air
conditioning available, or from extreme cold with no central heating. The foregoing is not an exhaustive list of
dangers that may arise but is illustrative of some types of dangers that may be faced. This release covers all
rights and actions of every kind, nature and description, which the undersigned ever had, now has or but for
this release, may have. This release binds the undersigned and his/her heirs, representatives and assignees.
Participant's Signature _________________________________________________________
…………………………………………………………………………………………………………………………………
Notarization of Liability, Medical, and Information 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, _____________________________Parish or County_____________________________
State of __________________________________My Commission Expires _______________________

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