HEALTH DECLARATION & RELEASE OF LIABILITY FORM
(1) HEALTH DECLARATION
~ CONFIDENTIAL~
The intent of this health declaration form is to collect essential health and medical information from the mission tripper in order to enable timely support in the event of unforeseen illness or emergency. This form will be kept in confidential with your trip team leader and will be discarded by your trip team leader upon return.
To be completed by Mission Tripper
(If the Applicant is under 21 years of age, parent or legal guardian is to assist in obtaining information)
PLEASE WRITE CLEARLY
Select the relevant Trip Information
*
Please Select
Sri Lanka 0604 0611 (LK0604S)
Japan Hokkaido 0607 0614 (JP0607S)
Indonesia Yogyakarta 0608 0610 (ID0608S)
Timor-Leste Bobonaro 0614 0621 (TL0614 )
Mongolia Ulaanbaata 0701 0709 (MN0701S)
Japan COOS Osaka 0721 0729 (JP0721S)
Timor-Leste Bobonaro 0726 0803 (TL0726S)
Centra Asia 0806 0816 (CS0806 )
South East Asia 0809 0815 (LA0809S)
Mongolia 0817 0824 (MN0817S)
East Asia XN 0903 0909 (EA0903S)
Japan Osaka(EHC) 0903 0909 (JP0903S)
Mongolia 0903 0910 (MN0903 )
East Asia 0906 0913 (EA0906 )
Indonesia Bali(Dick) 0914 0921 (ID0914 )
Japan Kobe (EHC) 0919 0927 (JP0919 )
Indonesia Bali(Dick) 1008 1014 (ID1008 )
Japan Osaka(EHC) 1017 1025 (JP1017 )
Thailand Chiang Mai 1017 1023 (TH1017 )
Philippines Iloilo 1026 1102 (PH1026S)
Japan Tokyo(EHC) 1026 1102 (JP1026S)
Japan Tokyo(EHC) 1101 1107 (JP1101S)
Timor-Leste Bobonaro 1108 1115 (TL1108S)
Japan COOS Osaka 1110 1115 (JP1110S)
Thailand Ban Chan 1201 1207 (TH1201S)
Japan Shizuoka(E 1205 1212 (JP1205S)
Indonesia Bali(Dick) 1208 1215 (ID1208 )
Japan COOS Osaka 1222 1228 (JP1222 )
Trip Code:
*
Country:
*
Location:
*
Start Date:(mmdd)
*
End Date:(mmdd)
*
Name as in Passport:
*
Gender:
*
Male
Female
Marital Status:
*
Single
Married
Divorced
Widowed
Passport No.:
*
Expiry Date:
*
-
Month
-
Day
Year
Please check if the passport expiry is more than 6 months
Date of Birth: (dd/mmm/yyyy)
*
-
Day
-
Month
Year
Date
Age
*
(years)
PDF file name
Email:
*
example@example.com
Contact No.:
*
Format: 0000-0000.
Health (tick one):
*
Excellent
Good
Fair
Poor
Blood Type (tick one):
*
A+
A-
B+
B-
AB+
AB-
O+
O-
I am not sure
Blood Pressure (tick one):
*
Normal
Low
High
History (Example: Medical / Surgical / Accident / Mental / Serious illness / Family / Nil)
*
Are you on any form of medication / doctor's care?
*
Yes
No
If Yes, please give details:
*
Do you suffer from or have been treated for any of the following? If No, please select 'Nil' below. If 'Yes', please select and provide the details below.
Do you suffer from or have been treated for any of the following?
*
Cancer
Epilepsy
Disease of Brain / Nervous System
Heart Disease
Chest Pain
Disease of Blood / Metabolism
Diabetes
Migraine
Disease of Kidney / Genito Urinary System
Hepatitis
Anaemia
Disease of Muscles / Bones
Stroke
Fainting Spells
Respiratory Disorder / Asthma
Nil
Other
Please give details of the sickness and treatment that you have selected above:
*
"Are you pregnant?
*
Yes
No
Do you have any allergies?
*
Yes
No
If Yes, please give details:
*
Have you ever been on a mission trip?
*
Yes
No
Emergency Contact
In case of Emergency, who should we contact? (Emergency contact
cannot
be the person going on the same trip.)
Full Name
*
Emergency contact
Relationship:
*
Home #:
*
Format: 0000-0000.
Mobile #:
*
Format: 0000-0000.
COOS Mission Trip 'Health Declaration and Release of Liability
(2) RELEASE OF LIABILITY
As a mission tripper for Church of our Saviour (COOS), I hereby release COOS from any liability or responsibility for injury to me of any kind, including, but not limited to, bodily injury, emotional distress, or economic loss, that I may sustain as a result of, or otherwise occurring while I am acting as a volunteer participating in the mission trips and programme in the country or countries that I signed up to be involved in. By this release, I intend that COOS will have no responsibility for any injuries to my person that occur during, or as the result of, my travel to or from my training or preparation location, while being trained or otherwise being prepared for my trip, as well as my actual travel within the country or countries. I voluntarily assume any and all risks that I may be detained and/or incarcerated by the authorities of the country or countries where I travel while engaged in my volunteer duties on behalf of COOS. I agree to hold COOS harmless in all respects if that should occur.
To be completed by Mission Tripper
Submission Date:
-
Day
-
Month
Year
Date
Signature of Mission Tripper & Date:
*
If the applicant is under 21 years of age, the consent of a parent or a legal guardian is required. *
*Consent of Parent/Legal Guardian
Name as in NRIC:
*
Consent of Parent/Legal Guardian
Signature and Date:
*
Relationship:
*
IMPORTANT:
It is
MANDATORY
for all mission trippers to have a valid travel insurance plan for the mission trip that provides coverage for (1) COVID19, (2) Hospitalization / Medical Expenses, and (3) Emergency Evacuation. Please provide us with the following information:
Travel Insurance:
*
Policy Number:
*
By signing this form, you agree that Church of Our Saviour may collect, use and disclose your personal data, as provided in this form, for the processing of this application with all relevant parties in accordance with the Personal Data Protection Act 2012.
~ End of Form ~
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