International Children's Outreach - Medical Release Form

Medical Release
Summer Missionary Training

I acknowledge that I will be participating in the Summer Missionary Training sponsored by International Children's Outreach. I assure the leadership I am in good health and able to participate. I give my consent for an attending physician or medical center to administer any medical treatment deemed necessary in the event of an emergency. I agree to be held responsible for any charges incurred or to use my own family medical insurance in the event of necessary medical treatment.

Information about you:

Applicant's E-mail:

Phone (daytime):

Phone (evening):

Applicant's Name:

Date:

Information about your Insurance:

Name of Insurance Provider:

Policy or Group Number:

Information about any medications, doctors, etc.:

Are you using any medication? Yes No

If so, what medications, and what are the instructions for its use?

Name of Family Doctor:

Phone:

Comments:

Information about you:
Applicant's E-mail:
Phone (daytime):
Phone (evening):
Applicant's Name:
Date:
Information about your Insurance:
Name of Insurance Provider:
Policy or Group Number:
Information about any medications, doctors, etc.:
Are you using any medication?	Yes No
If so, what medications, and what are the instructions for its use?
Name of Family Doctor:
Phone:
Comments: