Over 18 Medical/Liability Release Form
for
Laredo Stepping Stone/Mex Quest Int.
*Please know that all information listed on this form will be kept in strictest confidence by Laredo Stepping Stone and is only used for our information so we will be aware of any potential medical issues or in case of a medical emergency as permission for medical personnel to treat the person listed below. It will not be shared with ayone except group leaders or health care professionals if the need arises.
Today's Date_____________________
Name_____________________________________________ Age _________ Birthdate_______________
Address___________________________________________
___________________________________________
Phone_________________________________ Email____________________________________________
Insurance Information:
Name of Company_________________________________________________________________________
Address___________________________________________
___________________________________________
Group#____________________________________________ ID#__________________________________
Subscriber Name____________________________________ Birthdate______________________________
Employer (of subscriber)_____________________________________________________________________
Employer's Address__________________________________
__________________________________
Emergeny Contact Information:
Who do you want us to notify in case of an emergency? ______________________________________________
Relationship to you___________________________________
Home Phone_______________________________________
Work Phone________________________________________
Cell Phone_________________________________________
Medical Issues:
Please list any medical problems you have that we should be aware of.
___________________________________________________________________________________________
___________________________________________________________________________________________
Are you under the care of a physician?
____________________________________________________________________________________________
____________________________________________________________________________________________
Are there any physical limitations or chronic concerns that limit your activity? Please explain.
____________________________________________________________________________________________
____________________________________________________________________________________________
Are your immunizations up to date? ____________________
Do you take any perscription medications on a regular basis? If yes, please list below.
___________________________________________________________________________________________
____________________________________________________________________________________________
When was your last tetnus shot? ________________________
Do you have any allergies to foods or medications? Please List
____________________________________________________________________________________________
____________________________________________________________________________________________
Laredo Stepping Stone/Mex Quest Int. Trip Liability/Medical Treatment Authorization
I, __________________________________________________, do release Laredo Stepping Stone, its board, staff and all affiliated organizations, and/or sponsoring churches of any responsibility for accidental injuries, sicknesses or incidents sustained during our stay at Laredo Stepping Stone and any trips involved therein, including into Mexico or state side, run by Laredo Stepping Stone/Mex Quest Int. during the dates of __________________________________. I do hereby give the staff of Laredo Stepping Stone/Mex Quest Int. permission to hospitalize, secure proper treatment, and to order injection, anesthesia, or surgery as deemed necessary and in accordance with the previously stated medical history. I understand that pictures of groups and trips are often used in promotional materials and websites for LSS/MQI and I give permission to use any pictures of me or my likeness in such publications. I also acknowledge that I have read and agree to the terms and regulations listed for Laredo Stepping Stone/Mex Quest Int. and realize I may be asked to leave at any time at my expense for flagrant violations of those terms and regulations.
Please sign below in the presence of a Notary Public:
I, ___________________________________________ Date ________________________
Notary Information
I, __________________________________________, a Notary Public for said country and state
do hereby certify that ______________________________________, personally appeared before m
me this day and acknowledge the due execution of the foregoing instrument.
Witness my hand and official seal, this the _____________Day of __________________, 2______
Notary Public
Official Seal ____________________________________
