Name *
Phone # *
Email *
EMERGENCY CONTACTS, INFO AND RELEASE FORM
In the case of an unforeseen emergency on this ministry trip, the health and safety of our guests is of utmost importance to us and we want to be able to respond appropriately to the best of our ability. Please provide the following information.
Date *
Address *
City *
State *
Zip *
Date of Birth *
Your Age *
Martial Status —Please choose an option—SingleMarried
Your Spouse
Spouse’s Email
Spouse’s cell #
Do you have children? —Please choose an option—YesNo
Your Children’s Names & Ages:
Your primary physician: *
Physician's Phone # *
What is your blood type? *
Do you have any medical conditions we should be aware of if you are unconscious? * —Please choose an option—YesNo
If yes, please explain
People you want us to contact in case of emergency overseas:
Relationship to you *
Is there any reason why you might be physically or mentally challenged to travel and minister on this trip? * —Please choose an option—YesNo
Do you have any food/dietary needs on this trip? * —Please choose an option—YesNo
Do you have any food/dietary considerations on this trip? * —Please choose an option—YesNo
If Yes, please indicate what those needs will be.
Please list any allergies to medicines, animals and insects *
What are you bringing with you for these allergies? (pack in carryon, do not check in luggage)
List any medications you are on, the purpose of the medication and the dosage (pack in carryon, do not check in luggage).
Are you trained or certified to administer any medical assistance? * —Please choose an option—YesNo
Because of the terrain and moving about, we ask our travelers to be able to climb stairs easily and walk 5,000 steps per day. Can you do this? * —Please choose an option—YesNo
Shot/Immunization Record and Information:
When was your last Hepatitis A vaccine series completed? *
When was your last Hepatitis B vaccine series completed? *
When was your last tetanus shot? *
Routine vaccines:
The Center for Disease Control (CDC.com) suggests that before internationals trips, travelers are up to date on routine vaccines. These vaccines include measles-mumps-rubella (MMR) vaccine, diphtheria-tetanus-pertussis vaccine, varicella (chickenpox) vaccine, polio vaccine, (and a yearly flu shot if you choose to).
I am up to date on the vaccines listed above YesNo
I have received or plan to receive a current flu shot before the travel date YesNo
I will make arrangements to be up to date on the above vaccines before the travel date YesNo
I have chosen not to receive the vaccines listed above. Further, I understand it may jeopardize my acceptance by Indigenous Ministries to travel on this ministry trip due to the country/countries of travel. YesNo
Note: The vaccines listed above may or may not encompass full preparedness for this trip. Therefore, we strongly urge guests to visit CDC.com, look up the country Indigenous Ministries has invited them to, and follow the CDC’s advice on vaccinations and medical precautions to take before/during and after traveling to these areas. Additionally, we strongly suggest our guests consult with their physician and receive instruction and assistance with preparation medically for this trip.
List any other vaccines you have received: Vaccine
Date
MEDICAL PERMISSION: I authorize Indigenous Ministries International staff members, US or Indigenous (overseas), to obtain medical treatment for me in the event of injury or illness and agree to pay any expenses incurred for treatment. I give permission for the medical information above to be used in my medical care overseas. I understand that in an emergency, US Indigenous Ministries an national team leaders will do everything to get me the care I need, but may not be able to access the medical care I need if it is not available in that country or area.
By writing your name here, you agree this is your signature and you have filled out the Emergency Contacts, Information & Release form and filled it out accurately.
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