SUNCREST MISSIONS MEDICAL RELEASE FORM

SUNCREST WORSHIP
Medical Authorization and Emergency Treatment Consent
Mission Trip:
Destination:
Trip Dates:
Participant Name:
Date of Birth:
Purpose
This authorization is intended to allow Suncrest Worship and its designated mission trip leaders to obtain necessary emergency medical treatment if I am unable to make medical decisions for myself or, in the case of a minor participant, if my parent or legal guardian cannot be reached in a timely manner.
Medical Authorization
I authorize the designated Mission Trip Leader(s), or any adult leader appointed by Suncrest Worship, to act on my behalf in obtaining emergency medical evaluation and treatment during the mission trip when:
- I am unconscious, incapacitated, or otherwise unable to provide informed consent; or
- (For minors) a parent or legal guardian cannot be contacted within the time reasonably necessary to provide emergency care.
This authorization includes permission to:
- Arrange transportation to an appropriate medical facility;
- Consent to emergency examination, diagnostic testing, medical treatment, surgery, anesthesia, hospitalization, or other procedures deemed reasonably necessary by licensed medical professionals;
- Obtain prescription medications;
- Communicate with physicians, hospitals, emergency personnel, pharmacies, insurance providers, and other healthcare professionals regarding my care;
- Authorize transfer to another medical facility when medically appropriate.
I understand that all medical decisions will ultimately be made by the treating licensed healthcare professionals based on their medical judgment.

Limitation of Authority
This authorization applies only during the dates of the mission trip and only when I am unable to make or communicate my own medical decisions, or, in the case of a minor, when a parent or legal guardian cannot reasonably be reached. This authorization does not grant authority for non-emergency elective medical procedures unless separately authorized by me or my parent/legal guardian.
Medical Information
Primary Care Physician:
Physician Phone:
Format: (000) 000-0000.
Medical Insurance Company:
Policy Number:
Group Number (if applicable):
Allergies
Please list all allergies, including medications, foods, insects, and environmental allergies:

Medical Conditions
Please list all significant medical conditions, diagnoses, or health concerns:
Current Medications
Please list all prescription and non-prescription medications currently taken:
Medication Dosage Frequency
Emergency Contacts
Primary Emergency Contact
Name:
Relationship:
Phone (Primary):
Format: (000) 000-0000.
Phone (Alternate):
Format: (000) 000-0000.
Email:
example@example.com
Secondary Emergency Contact
Name:
Relationship:

Phone:
Format: (000) 000-0000.
Email:
example@example.com
Financial Responsibility
I understand that I (or my parent/legal guardian) am financially responsible for all medical expenses, transportation costs, prescriptions, hospital charges, evacuation costs, or other healthcare expenses that are not covered by personal health insurance or applicable travel insurance.
HIPAA Authorization
I authorize licensed healthcare providers, hospitals, clinics, emergency responders, pharmacies, and insurance providers to disclose medical information reasonably necessary for my diagnosis, treatment, transportation, insurance claims, and continuity of care to the designated Mission Trip Leader(s) and Suncrest Worship representatives during the mission trip. This authorization shall remain effective only for the duration of the mission trip unless earlier revoked in writing, except to the extent action has already been taken in reliance upon it.
Participant Certification
I certify that the medical information provided on this form is complete and accurate to the best of my knowledge. I understand that Suncrest Worship and its mission trip leaders are relying upon the information I have provided in planning for my care should an emergency arise.
Adult Participant
Participant Name:
Signature:

Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Authorization (Required for Participants Under 18)
I certify that I am the parent or legal guardian of the above-named participant. I have read this Medical Authorization and voluntarily grant the authority described above to the designated mission trip leaders of Suncrest Worship.
Parent/Guardian Name:
Relationship:
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

SUNCREST WORSHIP

Medical Authorization and Emergency Treatment Consent

Purpose

Medical Authorization

Limitation of Authority

Medical Information

Allergies

Medical Conditions

Current Medications

Emergency Contacts

Primary Emergency Contact

Secondary Emergency Contact

Financial Responsibility

HIPAA Authorization

Participant Certification

Adult Participant