Name (please print)
Name of Emergency Contact(s)
Participant's Physician in U.S.A.
I am traveling to
Departure Date from USA
Return Date to USA
Location in country
authorize a Heartline Ministries - Haiti representative, if I am unable to do so, to consent to any necessary examination, anesthetic, medical diagnosis, surgery, treatment, hospital care, and or evacuation 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 or country in which they practice, during the duration of the trip identified above. I assume the responsibility for all medical bills for myself. I also know that I am responsible for verifying with my insurance carrier that my current insurance policy will cover me while on this mission trip for which I am participating.
*Medical Insurance Provider
Policy Holder DOB
Physical requirements for this trip include (but are not limited to) being able to walk on rough roads, climb stairs, and climb in and out of a large truck. Please let us know before the trip if these requirements would be difficult or impossible for you.
List any medical conditions that those around you should know about in the event of an emergency. Be sure to apprise your Group Leader (if traveling with a group) before the trip. This is your responsibility.
*Medical Insurance: The coverage will be active for the duration of your stay in Haiti (approximately one week).
Your individual private medical insurance will be used to cover any illness or injury requiring medical attention during the trip while we are still in the United States (most travelers will have a layover in Miami, FL or Atlanta, GA)
PO Box 898, Sunnyside, Washington
United States , 98944
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