Medical And Liability Release Form printable pdf download

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 _______________________

Medical And Liability Release Form

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