Medical Release - Membership Required

Laboring in Mission to Neighbors in Need

Complete, Sign (before a NOTARY PUBLIC) and Fax the documents below to (214) 953-1332

          Adult Emergency Medical Information, Release and Power of Attorney (.pdf **)

           Youth Emergency Medical Information, Release and Power of Attorney
                   (at least 14 years, with parent and prior L4N approval. Contact Us.)


First Name*
Last Name*
E-mail Address*

My information on the front page of my Adult Emergency Medical Information form is true and correct and I consider myself healthy to participate on this mission trip.*	Agreed Rejected

I have read the Release on the second page of my Adult Emergency Medical Information form and I agree to its terms.*	Agreed Rejected

I have read the POWER OF ATTORNEY on the second page of my Adult Emergency Medical Information form and it is true and correct.*	Agreed Rejected

Next Steps

Or Print this page and enclose a check or money order for the fee and send to:

Labor for Neighbors, Inc.
c/o Cleve Clinton
1601 Elm Street, Ste 4100
Dallas, TX 75201