Consent for Medical Treatment jotform Logo
  • Give permission for my child to travel with The Evangelical Free Church of Eaton, from Eaton, CO, USA to Liberia Costa Rica for a mission trip July 1-10 +/-, 2026

  • In consideration of my participation in this mission trip, I hereby release and discharge The Evangelical Free Church of Eaton, 1325 3rd St, Eaton, Co 80615, its agents, drivers, sponsors, employees, members and officers, from all actions, claims, demands, judgments, and executions which the undersigned ever had, or now have or may have, or which the undersigned's heirs, executors, administrators, or signs may have or claim to have, against The Evangelical Free Church of Eaton, its successors, or signs, for all personal injuries, known or unknown, and injuries to property, real or personal, caused by, or arising out of, the above described activity.

    In case of emergency, I hereby give permission to the physician selected by Jason Newby, or any staff member assigned by him, to hospitalize, secure proper treatment for, and order injection, anesthesia or surgery for my child during the above referred to period of time. I do hereby waive all rights of prosecution against The Evangelical Free Church of Eaton and staff should an accident in which my child is involved, occur.

    I, the undersigned, have read this release and understand all of its terms. I have had any questions relating to this release of liability and claims explained to my satisfaction. I execute it voluntarily and with full knowledge of its significance and believe the same to be in my best interest.

  • YOU MUST SUBMIT A COPY OF YOUR MEDICAL INSURANCE CARD. 

    You may submit a copy in person or email a photo/copy to staff@efcofeaton.org or text a photo of it to Jason 970-590 5240

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  • Upon submission you will be re-directed to the Confidential Medical Questionnaire.

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