7722 Yelm Hwy, SE, Olympia, WA 98513, (360)
438-0455
Director of Missions:
Randy Ryan RandyR7750@comcast.net
Phone: (360) 459-2632
Mission Application & Emergency Information
Mission Trip: Romania
Medical Missions Dates: October 15 - 25
Name:__________________________________________________________________________________
(As it
appears on your passport; Please be exact!)
Address:_________________________________________________________________________________
______________________________________________________
Phone # __________________________
City State Zip County
Fax #__________________________________ E-mail
Address_____________________________________
Date of Birth ____________________________ Sex____________
Marital Status ___________________________ Name of
spouse ___________________________________
Passport# ______________________________ Date of
Expiration __________________________________
Passport Agency _________________________Date of
Issue _____________________________________
Place of Birth ____________________________Nationality
_______________________________________
In the event of an emergency, notify:
1st Name
_______________________________Relationship ______________________________________
Address ________________________________________________________________________________
Phone #
________________________________Work # __________________________________________
2nd Name
______________________________Relationship _______________________________________
Address _________________________________________________________________________________
Phone #
_______________________________ Work # ___________________________________________
Place of
Employment ______________________________________________________________________
Job Title
________________________________________________________________________________
Address
___________________________________________Phone # ______________________________
Please check one or more: __MD __Surgeon
__RN __LPN __DC
__PT __DMD __DA
___ Evangelist (includes – Pastor,
Sunday School Teacher, VBS Teacher/Helper, etc)
Church affiliation: (If
applicable) Name of church, Address,
name of Pastor and phone #
Name of
church:
__________________________________________________________________________
Address:
________________________________________________________________________________
Name of
Pastor: ______________________________ Pastor’s phone
#:______________________________
PLEASE SEND A COPY OF YOUR PASSPORT (Page with picture and signature), if you are medical
personnel also send a copy of your medical license.
Anticipated cost for the
2010 trip is $2,000.00
Deposit
Deposit
and Application: $250.00 by June 30,
2010
Airfare
Deposit: $1,200.00
by August 31, 2010
Balance due: $550.00 and airfare
difference by September 30,
2010
Amount
enclosed:_______________________
Please
make checks payable to SunBreak
Missionary Baptist
Church (please note for
Medical Missions) and mail to the address on the front of this form.
RELEASE
To whom
it may concern:
This is
to certify that I, ____________________________, am taking the following medications. ________________________________________________________________________________________________________________________________________________________________________________
Medications
I am allergic to: Other
allergies (foods, insects, etc…)
_______________________________ _______________________________
_______________________________ _______________________________
_______________________________ _______________________________
_______________________________ _______________________________
My
doctor’s name is _______________________________________________________________________
Address_________________________________________________________________________________Office
# ___________________________________Emergency#____________________________________
Further, I understand that in case of an emergency every
attempt will be made to contact persons listed on this form. In the event they
can not be reached, I hereby give my permission for the Doctor or medical
personnel selected by the Team Leader or Team member present, to hospitalize,
to secure medical treatment and/ or to order an injection, anesthesia, or
surgery as deemed necessary.
I also understand that my insurance
coverage will be used as primary coverage in the event medical intervention is
needed. I understand SunBreak
Missionary Baptist
Church and its agents
will take all reasonable safety precautions during this activity. I understand
the possibility of unforeseen hazards and know the risk involved in foreign
travel. I agree not to hold Sunbreak
Missionary Baptist
Church, its Leaders,
Employees, or volunteer staff liable for damages, losses, diseases, or injuries
incurred during this trip.
Further, the person herein has personal medical and
hospital insurance through:
_______________________________________Insurance Company, I.D and/ or Group # _________________________
Insurance
Company Address:
________________________________________________________________________
Insurance
Company Phone #:
________________________________________________________________________
Signature:__________________________________________
Date: ______________________