One27 Ministries, Inc.

Medical Information and Release Form

(Please complete both pages of this form and return to Katy)
Name: ______________________________________________________________________
Address: _______________________________ City: _______________ State: ____________
Zip: ____________ Email: ________________________________________
Day Phone: _______________________ Eve Phone: __________________
Medical History/Information
The following information may be referred to by any hospital or licensed medical practitioner:
Allergies: ________________________________________________________________________________
Current medical conditions: _________________________________________________________________
Physical impairments: ______________________________________________________________________
Please list any prescribed medication you will be taking during the mission trip: ________________________
Name of Physician: ________________________________________________________________________
Previous medical history: heart problems, depression, cancer, HIV, kidney, etc:
________________________________________________________________________________________
Please give a brief medical history of any of the above illnesses you have experienced:
________________________________________________________________________________________
Age: ______________ Height: ________________ Weight: __________ Blood type: ___________________
Have you been hospitalized during the past 2 years for any reason? If so, please indicate date(s) and explain
reason: _________________________________________________________________________________
If you are currently pregnant please state expected due date: ______________________________________
Only if you are currently under the care of a physician or psychologist, or have been
hospitalized during the past year, is it necessary for your physician or psychologist to
complete the following Physicians Statement.
PHYSICIANS STATEMENT:
Name of Patient: __________________________________________________________
Patient has been under treatment for: _________________________________________
The above named patient has been examined by me and found to be in satisfactory
health to travel and participate in the One27 Mission Trip: Date of Trip: _____________
________________________________________________________________________
Physicians Name (please print)

Phone

Fax

-----------------------------------------------------------------------------------------------------------Physicians Signature

Date

I give my permission for One27 staff to contact the above named physician for further
information regarding my health. _________________________________________________
Participants Signature

Date

(Please complete both pages of this form)

IMPORTANT INSURANCE NOTE:
One27 Ministries, Inc. will be providing short-term medical insurance for the duration of your trip.
The insurance will not cover trip cancellation. You may purchase at your own expense.
You will need to check with your current Medical Insurance Company to see if they will cover you
outside the U.S. If they will cover you, please fill out their information below:
Medical Insurance Carrier: _______________________________________ Policy #: __________
Name of Individual Policy Holder: ___________________________________________________
Company Name (if group policy) ____________________________________________________
Insurance Company Address: ______________________________________________________
Insurance Company Phone Number: _________________________________________________

I agree as follows: In the event of any accident, sudden illness, or medical emergency involving
myself in connection with the below named event, I hereby authorize One27 or One27 Staff or its
representatives, to consent to x-ray examination, anesthetic, medical or surgical diagnosis or
treatment and hospital care, deemed necessary by a licensed physician.
In consideration of being permitted to participate in the One27 Mission Trip, I, the undersigned,
hereby release, waive, discharge, covenant not to sue, agree to indemnify and hold harmless,
One27 Ministries, Inc. and or its officers, directors, agents, affiliates, employees and assignees
from any and all damages, liability, causes of action or any other form of liability, past, present or
future, and whether caused by the negligence of Releases or otherwise, arising out of or relating
to my presence or participation in the aforementioned One27 trip and any activities related
thereto, or any actions taken by Releases pursuant to the above medical authorization with
respect to myself.
This Release shall be binding on heirs, my executors, legal representatives, and myself.
_______________________________________________________________________________
Participants signature
Date
Person to contact in case of emergency:
Name: _________________________________ Relationship: ____________________________
Home Phone: ____________________________ Other phone: ___________________________
Address: _______________________________________________________________________

One27 Ministries, Inc.

1812 Southwood Dr.
College Station, Texas 77840
Email: lws1979@gmail.com