Peacemakers

Untitled Document

APPLICATION AND MEDICAL RELEASE FORM INFORMATION

Name	Male Female	DOB
Address	City	State	Zip
Home Phone	Cell Phone	Email

EMERGENCY CONTACT INFO

Next of Kin Name	Phone	Address
City	State	Zip
Email	Primary Care Provider	Phone

MEDICAL HISTORY

Do you have any medical conditions that may require special attention while on the mission trip (e.g. Seizures, Asthma, Diabetes, High Blood Pressure, etc.)

Do you have any allergies to medication?

Do you have any food allergies or special dietary needs?

List all prescription & over-the-counter medications you are taking

Date of Last Tetanus shot:

INSURANCE CARRIER (Make sure policy covers you overseas):

Policy Number

Group Number

Contact Phone

In the event of a medical emergency, I hereby provide authorization to be taken to the nearest licensed physician, medical center or hospital for medical treatment. I will be responsible for all medical costs not covered by my insurance.