Registration

Please enter information in the form below to process registration for event MISSION REGISTRATION. (Please fill out this form and turn it in before July 22nd, 2024)

A. BASIC INFORMATION

Full Name *

Phone Number *

Email *

Gender *

Occupation

Address *

City *

Zip

State

Church Name

Senior Pastor

B. MEDICAL INFORMATION

Emergency Name *

Emergency Phone *

Emergency Email *

Relationship *

What is one thing you are hoping to accomplish on this mission trip?

Please list any specific area you are interested in during your mission trip: (Prayer, worship, sharing Word, serving those in the villages, etc) What talents/gifts do you have that you feel can be used for the Lord?

Have you had previous experience in medical mission?

Please list any food restriction or allergies

Please list any medical training you have

C. Travel Information

What are your travel plans? *

Where will you be flying into? *

Will you be arranging your own transportation to wayanad, or will you need transportation from the airport to wayanad? *

D. OFFICIAL SIGNATURE - Medical/Liability Release and Policy Agreement

I realize that the limited charitable resources of Inter Collegiate Prayer Fellowship (ICPF) or Luke’s International Fellowship and Enrichment (LIFE) should not have to be dissipated on litigation. Therefore, I expressly waive my right to file a lawsuit in any civil court or other secular setting against ICPF/LIFE, its representatives and entities, other organizations, and all individuals involved with this missions trip. I hereby release all leaders and organizations involved with this mission trip from any and all legal liability.

I hereby waive all my rights to any legal liability on the part of ICPF/LIFE or any other individuals or organizations involved, from which liability may result from sickness, injury, or death that may occur on or related to this trip. I fully realize that there are hazards, and I am fully assuming these risks, including but not limited to: hazardous traffic, poor roads, food, allergies, dangers resulting from military or political problems, storms or hurricanes, sickness, injury, and disease. I specifically release ICPF/LIFE and its representatives from any claim of negligence in their duties as leaders or otherwise on this missions trip. In the event that I attempt to make a claim in violation of my release and waiver as herein indicated, I hereby agree to, and shall pay, all legal fees and costs incurred by ICPF/LIFE and other individuals and organizations involved.

In the event that it should become necessary, whether in an emergency or otherwise, I authorize ICPF/ LIFE and its adult individuals serving as its agents to arrange for any and all treatment including but not limited to: x-ray examinations, anesthesia, dental, medical, surgical, and/or treatment and/or hospital care for said participant on behalf of participant; and in such event, said participant agrees to pay for all costs, charges, fees, and expenses and travel and/or emergency expenses incurred as a result of treatment. The undersigned represents that the participant suffers from no disease or injury and has no other requirements for supervision, medication, or care other than those listed previously on this form. I assume the full responsibility for any and all medical bills and early evacuation/transportation costs incurred related to this missions trip.

I have read and am in full agreement with this release and waiver and policy agreement, and fully understand that I am waiving any rights I may have to litigate and sue. I accept full responsibility for visiting a doctor prior to the trip, all insurance, transportation to/from the host country, and all medical costs.

I realize I am legally responsible for and have read, understand, and agree to all the information previously listed on this Individual Registration form, including A. Basic Information, B. Medical Information, and C. Medical/Liability Release.

I Agree

YES