HSMT Registration - Student - White’s Chapel UMC

1 Participant Info

2 Medical Release Info

3 Over The Counter Info

4 Code of Conduct

5 Heartwork

6 Rebuild Together Release

7 Review and Submit

Participant Information
Participant's Name*
First Last
Date of Birth*
Gender*
- Male
- Female
T-Shirt Size*
Address*
Street Address Address Line 2 City State ZIP Code
Participant's Email*
Participant's Cell*
Class Year*
School (Fall of 2019)*
Students or leader I would like in my workgroup, or would like to room with:
WC Students guarantees to use at least one request in building workgroups.
Parent(s) or Guardian Information
Parent #1 Name*
First Last
Parent #1 Relationship*
Parent #1 Cell*
Parent #1 Email*
Parent #2 Name
First Last
Parent #2 Relationship
Parent #2 Cell
Parent #2 Email

White’s Chapel United Methodist Church Medical Release
Participant’s Legal Name*
Guardian Name*
City (Guardian)*
Release (required for all participating minors and adult sponsors)

I,(Guardian), city of, State of Texas, hereby affirm that (I, or my child ) shall be participating in activities sponsored by White’s Chapel United Methodist Church, hereinafter referred to as “the activities”. I certify that I am cognizant of the inherent dangers associated with participating in the Activities and with the fact that participating in the Activities may take place outside of, or off, premises. I understand and agree that neither White’s Chapel UMC, nor its trustees, nor representatives, nor instructors, nor agents may be held liable in any way for any occurrence in connection with my or my child’s participation in the activities that may result in injury, harm, or other damages to my family or me. As a part of the consideration for being allowed to enroll and participate in the Activities, I hereby personally assume all risks in connection with participation in the Activities. I further release White’s Chapel UMC, its trustees, instructors, agents, and representatives for any injury or damage which may befall while enrolled or participating in the Activities. I further agree to save and hold harmless White’s Chapel UMC, its trustees, agents, and representatives from any claim by me, or my family, estate, heirs, or assigns arising out of enrollment and participation in the Activities. I further state that I am of lawful age and legally competent to sign the affirmation and release: that I understand the terms herein and contractual and not a mere recital: and that I have signed this document of my own free act and coalition. I further state and acknowledge that I have fully informed myself of the contents of this affirmation and release by reading it before I have signed it.
Signature*
Date*
MM
DD
YYYY
Consent for Treatment
I,(Guardian), city of , State of Texas, hereby affirm that (I, or my child ) do hereby appoint the adult in charge of this event as his/her agent as my true and lawful, attorney in fact to act for me and in my name, place and stead; and to do any, every and all acts and exercise any, every and all powers that I might or could do in giving consent to emergency or non-emergency medical treatment for my minor child that he/she shall deem proper or advisable to do or exercise on my behalf. This appointment of the authorized adult sponsor as my attorney-in-fact for the limited purpose of consenting to emergency or non-emergency medical treatment for the above named minor child shall not terminate on my physical or mental disability subsequent to the date of execution hereof.
Signature*
Date*
MM
DD
YYYY
Medical Information
Is participant currently taking prescription medicine?*
- Yes
- No
If Yes, please list medication name, dosage and frequency.*
Does your student have any medical conditions that WC Students need to know about?*
- Yes
- No
If Yes, please describe the conditions*
Any allergies? [food, medications, etc.]*
- Yes
- No
If yes, please list them and give symptoms.*
Please indicate of any allergy is life threatening and/or requires an EpiPen.
Does the participant have any dietary restrictions?*
- Yes
- No
If yes, please desribe the restrictions.*
Date of last Tetanus (TDAP) shot: (M/D/Y):*
MM
DD
YYYY
Name of Physician*
Physician's Phone*
Group or Family Hospitalization Insurance Company*
Insurance Company’s Address
Group #*
Policy #*
Phone #*
In case of emergency and parent can’t be reached, call*
at*

OVER-THE-COUNTER (OTC) MEDICATION AUTHORIZATION FORM RELEASE FORM
White’s Chapel UMC Student Mission Trip & Events The White’s Chapel medical volunteers will provide basic first aid supplies to students (bandages, cold packs, etc.) as well as over-the-counter medications if deemed necessary by the medical volunteer.
All medications brought on Student Events must be checked in with the Team Leader and listed on the above Release Form. It is recommended that only necessary prescription medications be brought on the trip as the medical volunteers will have over-the-counter medications available if needed. If you have questions concerning this matter, please discuss with a medical volunteer.

Sign below if you agree for the medical volunteer to dispense any needed over-the-counter medication per package directions. Examples of these medicines include:
- Acetaminophen (Tylenol) or generic pain reliever/fever reducer
- Ibuprofen (Advil) or generic pain reliever/fever reducer
- Midol or generic menstrual cramp meds
- Benadryl or generic hay fever or upper respiratory allergies
- Nasal and sinus congestion meds
- Cough drops or throat lozenges for cough/throat irritation
- Dramamine or nausea medicine for motion sickness
If we do not have a parent or guardian’s signature, we will contact you prior to dispensing over-the-counter medications to your child.

I give permission for the medical volunteer to dispense over-the-counter medication(s) to my child for self-administration at the medical volunteer’s discretion or dispensed by designated personnel as delegated by the medical volunteer. Additional comments may be written below signature.
*
- I DO give my consent.
- I DO NOT give my consent.
Signature*
Date*
MM
DD
YYYY

CODE OF CONDUCT
ALL PARTICIPANTS (STUDENTS AND ADULTS) AGREE TO THE FOLLOWING BY READING AND SIGNING BELOW.
I will not participate in or have possession of illegal drugs, alcohol, firearms, or fireworks. I will abide by the laws of the state I am serving in. I know that illegal activity will be reported immediately to local authorities.

I will operate safely by not leaving the lodging campus without an adult 21 years or older. I will not change room assignments so my location is known in case of an emergency. I will respect the scheduled “lights out” time.

I will respect the privacy of others by not entering into areas designated for the opposite sex. I will honor people, places, and authorities by not using obscene language, acting in reckless behavior harmful to others or myself, respecting the local community by not damaging the facilities or properties.

I will respect others by not using tobacco at the work site, at the lodging facility, in the neighborhoods I serve in, and I understand that it is illegal to use tobacco on school grounds.

I will recognize and submit to the authority of the Heartwork Missions staff and the WC Students staff.

I will not engage in inappropriate sexual activity including obscene gestures, comments, or physical contact. I also know that such behavior will be reported to local authorities if warranted by law.

I know that I am a willing participant in a missions trip activity. I know that I may not have the conveniences of home. I will not bring valuables that cannot be stored with me at all times.

Out of respect for others, I will dress modestly. I will not behave in a way that causes distractions or disruptions to other participants.

In order to build relationships with my leaders and other students, I will not text message or use my cell phone, iPod, etc. on worksites or during worship programs.

ADULT SPECIFIC (21 AND OLDER)

I will serve as a positive role model for students and others. I will participate with a positive attitude and team effort during the missions trip.

I will show respect to the Heartwork Missions staff, WC Students staff, local authorities, leaders, and youth participants.
I will avoid and refuse to participate in any inappropriate sexual activity including comments, gestures, or physical contact.

I/We will respect God, the local community, and our youth group by abiding to this Code of Conduct. Violation of the Code of Conduct may forfeit the privilege of participating in this missions trip and I may be asked to leave (without reimbursement and at my own expense) at the request of the Heartwork Missions staff, WC Students staff, or my group leader.
Student Signature*
Parent Signature*

Tel: (970) 301-7070 Email: missions@heartworkmissions.com PO Box 727 Windsor, CO 80550
RELEASE AGREEMENTS RELEASE OF LIABILITY

I, individually, and in my capacity as parent, guardian, or next friend of any listed child, waive, release, and indemnify Heartwork Missions, its agents, employees, and volunteer assistants from any liability whatsoever arising out of any injury, illness, damage, or loss, which may be sustained by the participant during the course of involvement with this missions trip with Heartwork Missions. Furthermore, I agree to indemnify and hold Heartwork Missions, its staff, employees, volunteers, vendors, and agents harmless against all expenses, damages, costs which may incur from a lawsuit I might file. I fully recognize and understand that Heartwork Missions serves with subcontractors, schools, community agencies, churches, and other sponsors that are separate entities and organizations. Heartwork Missions is a separate and distinct organization.

MEDIA WAIVER RELEASE

I hereby understand that my child may be photographed and recorded during the trip. I authorize Heartwork Missions to use such material for its purposes

MEDICAL RELEASE

I authorize Heartwork Missions to use and provide my child’s health information in the event of medical treatment or payment as allowed by law. It is my responsibility to provide my child’s health insurance and to have that health insurance information available on the trip.

DISCIPLINARY PROCEDURES

I hereby recognize that all illegal activity will be immediately subject to the attention of local authorities. The Heartwork Missions staff and the local authorities will process all sexual misconduct incidents. Offenses against the Code of Conduct will be the responsibility of the youth leader or contact person. The Heartwork Missions staff is the final authority of this mission trip and on disciplinary action. The Heartwork Missions staff will immediately remove participants that are a threat to others, engage in illegal activity, or create unsafe and disruptive behavior during the missions trip.
Parent Signature*
I verify that I have read and agree to the above release agreements.
Date*
MM
DD
YYYY

Rebuilding Together: YOUTH EVENT VOLUNTEER FORM
In consideration of the opportunity afforded my child to assist Rebuilding Together Kansas City, Inc. (RTKC), in which the homes of disadvantaged persons will be repaired by volunteers, and in light of the aims and purposes of the community ser-vice provided by RTKC in organizing this event, I give my permission for my child to participate as a volunteer for RTKC, and I, on behalf of my child and myself, waive any right or cause of action arising as a result of my child's participation in any RTKC project from which any liability that may or could accrue against RTKC, or its officers and directors collectively or indi-vidually. Without limiting the generality of the foregoing, I, on behalf of my child and myself, agree that this waiver shall in-clude any rights or causes of action resulting from personal injury to my child or damage to my child's property sustained in connection with my child's activities while volunteering for RTKC. Further, my child is a volunteer that provides services on a purely charitable & voluntary basis. I agree to hold RTKC, and all people participating in any RTKC project, blameless for any accident involving my child while in transport while volunteering for RTKC. I understand that in the case of an accident, illness, or injury to my child, an adult volunteer will try to phone the emergency contacts provided, and I will allow them to secure medical treatment for those health conditions. If need be, I give permission for the attending physician to provide the proper treatment and to hospitalize if necessary. I, the under-signed, release RTKC, RTKC workers, donors/supporters/shareholders of RTKC, and anyone participating on behalf of RTKC from all liability in case of illness or injury at all times while my child is volunteering for RTKC. If we do not carry health insur-ance, then RTKC and its participants are not responsible for the expense of any medical treatment received. By signing my name below, I also hereby consent to the use of photographs and/or videos of those identified below and/or the statements attached hereto, including my personal name or the firm name, by Rebuilding Together Kansas City and its subsidiary and affiliated companies and their respective dealer and distribution organizations for advertising or publicity in printed, recorded or electronic media. I represent that I am of legal age and that I have authority to give this consent which will remain in effect until revoked by me in writing.
Parent Signature*

Almost done! Kindly review all info is correct.*
- I have reviewed that all info is true and correct

2019 High School Mission Trip - Student

Participant Information

Parent(s) or Guardian Information

White’s Chapel United Methodist Church Medical Release

Consent for Treatment

Medical Information

OVER-THE-COUNTER (OTC) MEDICATION AUTHORIZATION FORM RELEASE FORM

CODE OF CONDUCT

RELEASE AGREEMENTS RELEASE OF LIABILITY

MEDIA WAIVER RELEASE

MEDICAL RELEASE

DISCIPLINARY PROCEDURES

Rebuilding Together: YOUTH EVENT VOLUNTEER FORM