Medical Information & Waiver Liability & Medical Treatment Release Form Name* First Middle Last Please use the name that is on your passport.Trip Dates (Depart)* Date Format: MM slash DD slash YYYY (Return)* Date Format: MM slash DD slash YYYY I do certify that I will be traveling to Honduras, Central America, to participate in the Tegucigalpa and San Matias, LTCare Ministries, Ministries of Divine Mercy (MDM Honduras) & Operation New Life outreach. I hereby release LTCare Ministries, Ministries of Divine Mercy (MDM Honduras), Operation New Life, DIME Hospital, and Hospital Escuela and their appointed agents, and any other hospital or ministry worksites, from any and all liability as a result of any accident, sickness or death that I may incur while participating in this outreach. Furthermore, I authorize the leadership of Love Truth Care Ministries, Ministries of Divine Mercy (MDM Honduras) & Operation New Life to take me to a doctor for medical treatment, emergency surgery and/or hospitalization should the need arise. I assume total responsibility for payment of all bills associated with the above-mentioned medical attention.Insurance Company:*Phone Number:*Policy Number:*Group Number:*Note: U.S. Medical Insurance does NOT typically cover you outside of the U.S.A.Is this travel insurance?* Yes No Finally, should it be necessary for me to return to the United States for any reason prior to the established return dates, I assume total responsibility for payment of all associated transportation costs.Participant's Signature*As shown on passport.Date* Date Format: MM slash DD slash YYYY Parent's SignatureFor minorsDate Date Format: MM slash DD slash YYYY Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Emergency ContactsName* First Last Relationship*Phone Number*Name* First Last Relationship*Phone Number*Are you currently under a doctor’s care for any medical condition(s)? Please list:Please list all prescription medications you are taking:NameDosageCondition/ Reason What is your blood type?*Are you pregnant?*YesNoDue Date Date Format: MM slash DD slash YYYY Personal Physician’s name and phone number:*