Medical and Liability Release Forms

Fill out the information Below

 

Medical and Liability Release Form

What trip are you interested in?*

What Conditions Apply?*

Describe Medical Condition

Have you received medical clearance from your doctor to participate in missions?*

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Are you currently taking any medication?*

N/A is acceptable if you have no allergies

Do you use tobacco?*

Do you use illegal drugs?*

How often do you consume alcohol? *

Mission Trip Waiver

NORTHSIDE BAPTIST CHURCH VOLUNTARY MISSION TRIP WAIVER AND RELEASE 

 

 

STATE OF GEORGIA

COUNTY OF LOWNDES

 

I, the undersigned, hereby offer to volunteer my time and services to serve as a missionary for the furtherance of the Gospel of Jesus Christ on the mission trip described above.  I understand and hereby warrant that I am not a compensated employee of The Northside Baptist Church of Valdosta, Georgia, Inc. with regard to this mission trip.  I understand this mission trip entails considerable risk.  I have prayerfully considered the dangers associated with missions in general and I have also carefully considered the political climate of the world in general, and of the regions that I will or may travel through, including any ground and air travel, and the region where I will ultimately serve.  I am aware of the hazards and risks to my person and my property associated with my service on this mission trip, including, but not limited to, death or injury by accident, disease, terroristic acts, weather conditions, inadequate medical services and supplies, criminal activity, and random acts of violence.  

Therefore, I, the undersigned, for myself, my heirs, personal representatives, executors, administrators, and assigns hereby indemnify, waive, hold harmless and forever release The Northside Baptist Church of Valdosta, Georgia, Inc. from and against any claims for damages that might arise due to my death, personal injury, loss of property or property damage, and against any claims anyone else might have against me for my personal acts, directly or indirectly related, which may accrue during, or subsequent to, my voluntary service on this mission trip. 

In consideration of this opportunity to participate in the kingdom building work on behalf of my Lord and Savior and to His greater glory, I provide this Waiver and Release of my own free will, absent of any coercion or undue influence.  I have carefully read this Waiver and Release and fully understand its contents and implications.  I am aware that this is a legal document that provides a release of liability against The Northside Baptist Church of Valdosta, Georgia, Inc.   

 

 

 

 

Consent form for Media Recording

I, the undersigned, do hereby consent and agree that the Northside Baptist Church Valdosta, GA inc. employees, volunteers or representatives have the right to take photographs, videotape, or digital recordings of me and to use these in any and all media, now or hereafter known, and exclusively for the purpose of public relations.  I further consent that my name and identity may be revealed therein or by descriptive text or commentary.

 

I do hereby release to the Northside Baptist Church Valdosta, GA inc., its employees, volunteers or representatives all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies.  I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used.

 

I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback.

 

I also understand that the Northside Baptist Church Valdosta, GA inc. is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sicknes or injury incurred as a result.

 

My electronic signature below represents that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

You must be 18 years or older or must be signed by parent or legal guardian.

Medical and Treatment Consent Form

I understand the Northside Baptist Church Valdosta, GA inc. works very hard to ensure the work of this ministry takes place as scheduled, and that all safety precautions possible are in place.  I understand there can be unforeseen events, emergency situations, and other conditions beyond the control of the Northside Baptist Church Valdosta, GA inc..  

 

I understand travel to developing countries can be dangerous and that I may be exposed to diseases and other medical issues not encountered in the United States.  I understand the risk of some of these issues can be significantly mitigated by receiving proper vaccinations and consistently taking medication (i.e. malaria prophylaxis).  While the Northside Baptist Church Valdosta, GA inc. may offer an opinion based on our experience as to the best course of action regarding vaccinations, etc, I realize it is my responsibility to confer with my doctor, local Health Department, and/or local travel clinic regarding the best course of action for me.  I recognize the default source of pre field and on field prophaylaxis information is the US Centers of Disease Control (www.cdc.gov).  

 

I understand travel insurance providing emergency medical evacuation is part of the cost of my trip but that all expenses arising out of an emergency medical or other situation might not be covered by this insurance.  Though my personal health insurance may cover the extra costs, I realize any remaining cost will be my responsibility.  While I understand every reasonable attempt will be made to contact my Emergency Contact as quickly as possible should I become injured I recognize this may not always be the case.  Therefore, I authorize the Northside Baptist Church Valdosta, GA inc. staff, agents and their representatives to obtain medical care for me in the event I am incapacitated and unable to make medical decisions for myself.  I release the Northside Baptist Church Valdosta, GA inc. from any liability for accidents or injuries that may occur, and from financial liability in the event of any accident or injury that may occur during my volunteer period.