VIM Medical & Liability | Mccurdy Ministries

McCurdy Ministries Medical & Liability Release Form

Each adult from your mission team must complete the Medical & Liability Release Form below. By completing this form online, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your handwritten signature and you consent to the legally binding terms of this Agreement.

Medical Release

First, Middle, Last Name

authorize

Team Leader Name

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 in this form.

VIM Team

Team Service Start Date

Birthday

Team Service End Date

Home Physician

Medical Insurance Provider

Allergies

Physician Phone Number

Insurance Phone Number

Blood Type

Medications (include name and dosage)

Do you have Diabetes?

Yes

Do you have seizures?

Yes

Describe any physical limitation(s)

Additional Medical Information

Liability Release

The undersigned releases and agrees to hold harmless McCurdy Schools of Northern New Mexico (trade name is McCurdy Ministries), 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 McCurdy Ministries VIM Team Project. The undersigned has been advised and understands that the project may involve risks to participants. Those risks may involve accidents while working or travelling, and illness due to geographic features such as high altitude, which may have a deleterious effect on persons with heart conditions or respiratory diseases. The foregoing is not an exhaustive list of risks that may arise but is illustrative of some types of risks 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 their heirs, representatives, and assignees.

Participant's Electronic Signature

By typing your name, you consent to the terms outlined in this Agreement.

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