Medical Release

MEDICAL RELEASE

Please note - Minor applicants (under age 18) must sign and scan a downloaded hard copy with the signed permission of a legal guardian. Applicants over 18 may submit a hard copy OR submit the online form at the bottom of this page.

All scanned copies may be emailed to trips@gpartners.org.

PRINTABLE FORM

Click here to download...

ONLINE FORM

(FOR AGES 18 AND OLDER)

* Participant Name (full name)
* Address
* City
* State
* Zip Code
* Phone
* Email
* Date of Birth mm/dd/yyyy
* Insurance Company
* Policy Number
* Emergency Contact Person #1
* Emergency Contact Person #1 Phone
* Emergency Contact Person #2
* Emergency Contact Phone #2
* Beneficiary (insurance policy owner)
* Relationship to Primary Beneficiary (self, spouse, etc)
Medical Allergies
Medications Being Taken (please list all)
Medical Problems or Other Pertinent Information
Special Requests
WAIVER OF LIABILITY STATEMENT: I understand Global Partners in Peace and Development (GPPD) will attempt to notify emergency contact in the event emergency medical treatment is required. If the emergency contact cannot be reached in a timely manner, I give GPPD, its staff,and/or associates permission to secure services of a licensed physician to provide necessary care, including anesthesia, for my well-being. I release GPPD, its staff, and/or associates from all legal claims and/or financial responsibility resulting from injury, illness, or death that may be sustained while participating in the activities of GPPD.
* I have read the information above and agree to the waiver of liability/consent to treat	* I have read the information above and agree to the waiver of liability/consent to treat
* Participant Name
* Today's Date
* Dates and Country of Mission Work
* I have read and understand the information provided by GPPD regarding vaccines in the country to which I plan to voluntarily travel.	* I have read and understand the information provided by GPPD regarding vaccines in the country to which I plan to voluntarily travel.
* I have willfully chosen to acquire/not acquire the vaccines recommended by the CDC for my country of travel.	* I have willfully chosen to acquire/not acquire the vaccines recommended by the CDC for my country of travel.
Check here if you have the Yellow Fever Vaccine (Required for Uganda). Please submit documentation along with this form	Check here if you have the Yellow Fever Vaccine (Required for Uganda). Please submit documentation along with this form


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