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ELEVATION SHORT-TERM MISSION TRIP MEDICAL RELEASE FORM
Please complete the following questions to participate in your short-term mission trip ONCE YOUR REGISTRATION HAS BEEN VERIFIED. Participants are not confirmed until the Registration, and Code of Conduct Agreement/Consent/Release of Liability, and Medical Release Forms are completed, and a copy of your passport to given to the Mission Team Leader.
IMPORTANT NOTICE:
It is HIGHLY recommended that you contact your health care provider for recommendations regarding inoculations and/or medications for the itinerary of this trip, as Elevation and Mission Team Leaders are not able to advise individuals on what they may or may not need. Contact the Mission Team Leader for information regarding the itinerary and specifics of your trip.
Your Full Name: *
Your answer
Insured's Name (if other than yourself):
Your answer
Insurance Carrier Name: *
Your answer
Policy Number: *
Your answer
Group Number:
Your answer
Doctor/Provider Name: *
Your answer
Doctor/Provider Phone Number *
Your answer
Medical History (list any medical problems we should be aware of):
Your answer
Allergies (list what actions are to be taken if problems arise):
Your answer
Required medications that you will be bringing with you:
Your answer
Is your Tetanus vaccination current? *
Date of last Tetanus vaccination: *
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