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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.
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.
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:
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 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.
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.
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
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.
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.
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