Consent for Medical Treatment
Whereas, I, (insert name here), wish to be a member of the Life Pacific College Cross-Cultural Team, which will be travelling to and staying in (insert country here), and whereas, certain circumstances and situations may occur resulting in my need for medical/dental care and treatment, and further resulting in my inability to personally give consent for such care and treatment:
1. I, (insert name here), being of legal age, authorize Life
Pacific College or any agent of Life Pacific College, to act in
my behalf should I be unable to do so and to consent to
reasonable medical/dental care and treatment, including
but not limited to diagnostic testing, x-ray examination,
anesthesia, surgery, or other procedures which may be
deemed necessary for my medical well-being for the
duration of the mission trip.
2. This consent is given in advance of any specific diagnosis,
treatment, surgery, or hospital care required, but is given
to provide authorization and specific consent for
medical/dental treatment and care on my behalf.
3. Any consent by Life Pacific College shall have the same
force and effect as if I had personally given the consent.
4. I understand that medical insurance in foreign countries,
provided by Life Pacific College, is included in the trip cost.
It covers $75,000 for accident or illness, $7,500 for trip
interruption due to injury or illness, $10,000 for political
evacuation, $100,000 for accidental death and
dismemberment, and up to $500,000 for medical
emergency evacuation (air ambulance).
5. I hereby release and hold harmless Life Pacific College, its
officers, employees, and representatives/volunteers from
all liability personal injury, including death, as well as all
property damage or loss arising out of my participation in
6. My passport # is: (insert number here), Country where
passport was issued: (insert name here)