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SHORT TERM MISSION TRIP
Full Legal Name __________________________________________________________________________
Date of Birth ________________________________ Age _____________ Gender ________________
Home Phone ________________ Cell Phone________________ E-mail Address _____________________
Passport Number _________________________________ Country of Citizenship ___________________
Place and date of issue ____________________________ Expiration Date _________________________
List previous citizenships, if any ____________________ Place of Birth ____________________________
You need to have a passport, valid for at least 6 months AFTER the end of the trip.
Explain why you feel motivated to go on this trip:
List previous overseas experience (country, length of stay and purpose of trip):
Please describe how you came to know Jesus Christ as your Savior:
What are your habits of Bible study and prayer? How have you grown spiritually in the last year?
How regularly do you attend church/church-related activities? Are you involved in other ministries outside LMCM?
In the last year have you used tobacco, alcoholic beverages or drugs? Ž Yes Ž No If yes, please explain how recently, how frequently, and in what quantities.
Name ________________________ Address____________________________________________________
Phone Numbers _______________________________________ Relationship _________________________
Please return your completed Application, Health Questionnaire, and Release and Assumption of
Release forms to: Living Hope Ministries, 12700 Hillcrest Rd, Ste 254 Dallas, TX 75230
RELEASE AND ASSUMPTION OF RISK FORM
1. I acknowledge that I have voluntarily applied for enrollment in the above listed short term
mission trip and in consideration of being permitted to participate in such trip, do voluntarily execute this “Release and Assumption of Risk” in behalf of myself, my heirs and next of kin, my personal representative and my estate.
2. I acknowledge that I have been fully informed of the nature, scope and demands of the trip, and
that I have met all of the prerequisites required for participation in this trip.
3. short-term mission trips usually involve a number of risks that may not be covered by
insurance. The form below is for use by volunteers of Living Hope Christian Ministries (LHCM) who participate on a trip that involves travel inside and outside of the United States. It is quite likely that LHCM will not have insurance to cover injuries or accidents that occur on such trips, and typically, LHCM has no means of adequately supervising all activities involved on the trip. As a result, LHCM may ask volunteers who participate on such trips to assume all risks associated with them as a condition of their participation. In such cases, a form similar to this one is often used.
4. I am aware of the hazards and risks to my person and property associated with serving in a
missions capacity, such hazards and risks including, but not being limited to, death or injury by accident, disease, war, terrorist acts, weather conditions, inadequate medical services and supplies, criminal activity, and random acts of violence. I accept my assignment with full awareness of these risks, and, subject to any insurance coverages that may be available to me from any source, and only with respect to LHCM and its agents, officers, directors, and employees, I voluntarily assume all risks of death, injury, and illness associated with such risks, and any damage to my personal property, and I release said LHCM and its agents, officers, directors, and employees from any liability whatever arising as a result of death, injury, or illness that I may suffer as a result of participation in the missions trip. I further recognize that such risks have always been associated with missionary service. 2 Corinthians 11:23-28.
5. I understand that every care and attention will be given to the health and comfort of the
members/volunteers, but LHCM or its staff cannot be held liable for any injuries sustained which were not directly caused by their failure to take due care.
6. I hereby authorize the leader of the trip to secure such medical advice and services as may be
deemed necessary for the health and safety of myself (or my son/daughter/ward) and I agree to accept financial responsibility, including in excess of the benefits allowed by provincial health insurance plans:
a. Where the health and well being of the applicant is involved. b. Where all attempts to contact the parent or guardian have failed or where due to the
nature of the emergency there was insufficient time to contact such parent or guardian. It shall be at the discretion of the leader of the trip as to what action must be taken for the welfare and safety of the member/volunteer.
7. I declare that I am in good physical health and believe that I am able without reservation or
limiting conditions to physically withstand and cope with the indicated activities of this trip.
8. I accept and assume full responsibility for all harm and injury, of every nature, including death,
which may occur to me or which I may suffer, and for all damages or loss to any personal property or property issued to me by LHCM, while I am participating in the trip and, in furtherance thereof, I agree to indemnify and hold harmless LHCM, and its employees, from and against any and all claims, demands, actions or causes of action, on account of damage to personal property, or to my personal injury, or death, which may occur or result directly or indirectly from my participation in the activity, and which results from causes beyond the control of and without the fault or negligence of LHCM and its employees.
9. I agree to abide by the rules and regulations imposed on participants by the agency and its staff.
10. I agree that I will be cooperative and helpful to and with all other participants in the trip and
will not be disruptive of the objectives established for the trip or as may be designated by the staff or group consensus.
11. I request that this “Release and Assumption of Risk” be construed and interpreted pursuant to
the laws of the State of Texas, and if any portion thereof is held invalid, I request that the reminder continue in full force and effect.
Signature of Parent/Guardian (if under 18)
: Please have 2 witnesses observe your signature, and have them sign below. They
must be at least 18, and should not be relatives.
Please make a copy for your records
Name:__________________________________ Date of Birth (dd/mm/yy):__________________
Height:_________ Weight:_____________ Blood type:_______ Date:________________
5. Insulin or other drugs to control blood sugar
8. Digitalis or other drugs for heart trouble
9. Allergies (foods, animals, medicine, pollens)
15. Been under medical care for serious illness
22. Are you pregnant/ think you might be
Do you have any other disease, condition or
Do you have any health problems or physical
limitations that might hinder your work in a
different climate, high altitude or adverse living conditions?
If you answered yes to any of the above questions, please give a brief explanation below. List any medications you would be taking along on the trip, along with any other dietary restrictions. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Consultant Physician, Dept of GU Medicine• To distinguish normal/variants of normal • Different causes of genital lumps and of oily secretions that keep the skin healthy & mistaken for warts –they do not change in size but warts do(especially in women) & may be mistaken for warts ‘Cord like’ swelling, usually just below the head of the penisUsually ca
NIKP-GLIMEPIRIDE TABLET 3mg Nichi-Iko unconsciousness. The clinical picture of severe reduced blood sugar level Taking NIKP-GLIMEPIRIDE with food and drink Tell your doctor immediately if you experience any of the following Glimepiride 3mg Alcohol intake may increase or decrease the blood sugar lowering action of symptoms: NIKP-GLIMEPIRIDE in an unpredictable way. Allergic