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Medical Release Form

Your Details

Emergency Contact Details

(Husband/Wife; Parent; Child; Friend)

Serving Details

I authorize the above named adult and above named missionary sponsor, if I am unable to do so, to consent to any necessary examination, anesthetic, medical diagnosis, surgery, or treatment and/or hospital care rendered to me under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine by the state or country in which they practice, during the duration of the trip identified above.

Any medical conditions which those around you should know about in the event of an emergency? List here and also be sure to apprise your missionary sponsor: your group leader (if traveling with a group) before the trip. This is your responsibility.
(if known)

Medical Insurance that would cover an emergency or injury in Honduras is strongly recommended. If you do not currently carry such coverage it can be obtained on a short term basis through I.M.G.’s Group Outreach Travel Plan. An I.M.G. Group Outreach Travel enrollment form can be obtained at or by contacting the Cornerstone office.

Maximum file size: 419.43MB

By submitting this form I am stating that all information above is true, accurate and complete.