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Florida Boulevard Baptist Church Mission Ministry
Medical/Permission & Release Form

Name:  
Address:  
City:  
State:  
Zip:  
Age:  
Date of Birth:  
Gender:   Male  Female
Marital Status:   Single  Married Divorced  Widowed
Home Phone:  
Work Phone:  
Cell Phone:  
Your name EXACTLY as it appears on your passport: 
Passport No:  
Expiration Date:  
In case of emergency notify:
Home Phone:  
Work Phone:  
Cell Phone:  
Family Physician:  
Physician's Phone No.:
Family Insurance Co.:
Policy No.:  
Immunizations:   Tetanus
Check all that apply   Polio Booster
    Measles
    Mumps
    Other
PAST MEDICAL HISTORY
Check all that apply   Asthma
    Sinusitis
    Bronchitis
    Kidney Trouble
    Heart Trouble
    Back Trouble
    Diabetes
    Dizziness
    Stomach Upset
    Hay Fever
    Other
Allergies: Food  
  Penicillin or other drug (name):
  Insect stings/bites:
  Poison oak, ivy, sumac:
List current medications:  
Wear Contact Lenses: Yes  No
ARE THERE ANY MEDICAL CONDITIONS, PHYSICAL, MENTAL OR EMOTIONAL THAT COULD POSSIBLY POSE A CHALLENGE UNDER STRESSFUL SITUATIONS ON THE MISSION FIELD? Please List here…
 
PLEASE BE ADVISED WHILE THESE ARE NOT REQUIRED, SUGGESTED SHOTS  ARE  Tetanus, Hepatitis B & C.  Additional shots may be required for a specific area at which time you will be notified.
PERMISSION FOR TREATMENT

My permission is granted to the Florida Boulevard Baptist Church staff members or adult sponsors in charge of the mission trip to to make provisions for any medical care which may be deemed necessary by a licensed physician for me and make any other decisions or give any other consents which may be necessary for my health or welfare at any time during the duration of the above event. I understand that should a health emergency arise the person listed above will be notified, but if they cannot be reached by phone, the leaders or adult sponsors should act as my agent to consent to any treatment deemed advisable by and rendered under the supervision of a physician or surgeon properly qualified and licensed under the law. I/we, the undersigned, do hereby release, remit and forever discharge all staff, adult sponsors, and Florida Boulevard Baptist of Baton Rouge, LA, from any and all claims, demands, actions or cause of action, past, present or future arising out of any damage or injury while participating in the event.

Dated this day of , 20

 Signature      

Statement: Please make sure the information you have provided is correct. If necessary, we may ask for additional information in order to make arrangements for a specific trip.

FIELD
Name of Mission Project: 
Dates of Project:  
Location:  
Please indicate any foreign language training, special skills, talents or Christian service experience that you feel may be helpful on the field:
   
Please list mission experience:
Country Mission Organization Dates Ministry
INVOLVEMENT
Check one:    
Church Membership Florida Blvd Baptist
      How long
  Other Church
      Name 
      List the ministries in which you are active at your church
     

If not a member of FBBC, we must have a letter of recommendation from your Pastor, forward to
          Florida Boulevard Baptist Church
         10915 Florida Blvd.
          Baton Rouge, LA 70815       Attention: Missions
List the ministries in which you have been involved with at FBBC:
   
What small group Bible Study are you currently involved in?
   
How would you describe your daily relationship with Jesus Christ?
   
What are your spiritual gifts?
   
In what areas of your life have you been in spiritual growth?
   
Have you had training in personal evangelism?
 Yes  No
     Please explain:    
   
TESTIMONY

In the space provided below, please share you salvation testimony. Please include how long you have been a believer, how you were saved, and describe your walk with the Lord at the present time.

 

  
Briefly describe why God is calling you to participate on this trip. 
   
What do you see as your role on this ministry team?
   

 
     
 

--Florida Boulevard Baptist Church ~ 10915 Florida Boulevard ~ Baton Rouge, LA 70815 ~ (225) 272-3740
 

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