2017 Parkway Fellowship Student Ministries

Transcription

1 2017 Parkway Fellowship Student Ministries Medical Release Form I (we) hereby give permission for my (our) child to attend and participate in activities sponsored by Parkway Fellowship and Student Ministries. I (we) hereby authorize Parkway Fellowship to transport my (our) child to or from the sponsored activities and events. I (we) hereby DO consent or DO NOT consent Parkway Fellowship to use pictures taken during this event for promotion of the Student Ministry. I (we) hereby authorize Parkway Fellowship and its acting leaders to teach and lead my (our) child in religious lessons and services which may include prayer and Bible teaching. I (we) hereby authorize any adult, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis treatment, and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the medical practice act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at the said hospital. I (we) hereby DO consent or DO NOT consent to the use of blood and or blood products under the care of a licensed physician in the case of an emergency. I (we) hereby do authorize any leader of Parkway Fellowship to dispense to my child any necessary over-the-counter medications (according to proper dosage instructions) when deemed necessary. I (we) hereby authorize any licensed physician or medical treatment center to treat my (our) child in case of an emergency in which the before named physician cannot respond. The undersigned adult shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for my (our) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. I (we) hereby release, forever discharge and agree to hold harmless Parkway Fellowship and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned adult the child-participant that occur while said child is participating in any trip or activity with Parkway Fellowship. Furthermore, I (we) [and on behalf of my (our) child-participant if under the age of 18 years] hereby assume all risk of personal injury, sickness, death, damage and expenses as a result of participation in recreation and work activities involved therein. Further authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agrees to hold harmless and indemnify said church, its directors, employees, volunteers and agents for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. The medical consent and liability waiver provisions hereof shall remain in full force throughout 2017 and in effect until written notice of revocation or withdrawal is received by Parkway Fellowship at its office at FM 1093, Richmond, Texas is the responsibility of the parent or guardian to notify the church of any changes in medical condition, guardianship, address or phone change in writing to the address listed at the beginning of this form. / / Father Date Mother Date / / Legal Guardian Date PARTICIPANT/STUDENT Date ********************************************************************* (Please Complete Both Sides)

2 Medical Form Student Name Age Birth Date Grade Address Phone City State Zip Sex (circle): Male Female School Attending City Father Cell Phone Mother Cell Phone Guardian Main Phone In Case of Emergency and Parent or Guardian cannot be reached, pleasecontact: Name Phone Relationship Family Physician Office Phone Family Dentist Office Phone Hospital Insurance No. Policy Number Primary Insured Name of Insurance Company Insurance Company Phone Numbers List date of last immunization: DPT MMR List date of last immunization: Tetanus Only Polio Check if student has had: Chicken Pox Measles Mumps Whooping Cough Other Allergies: Foods Medications Insects/Bites Previous Serious Illness Date Current Medication(s) Special Diet Other Important Medical Information Covenant of Conduct In all meeting, retreats, or other events ender the sponsorship and/or guidance of Parkway Fellowship, I am representing the Christian community and I am responsible for my actions. I understand the following guidelines will be followed: 1. The use or possession of illegal drugs, alcoholic beverages and tobacco are prohibited. 2. All conduct shall be in keeping with the highest Christian regard and respect for all persons. 3. All clothing shall be in good taste and in accordance with the dress requested for the Church event. 4. All individuals are expected to join in group activities. 5. No profanity or sexually inappropriate behavior. I understand the above Covenant of Conduct, and I agree to abide by it to the best of my ability. Student Signature: Date:

3 17 & Younger Liability Release Statement of Activities and Release of Participation Liability Form For Blueprint Ministries Participants Aged Seventeen and Younger, to be Completed by Parent/Guardian Operation Restoration (OR), d.b.a Blueprint Ministries, Incorporated, is an inner city home repair ministry in San Antonio, Texas. Blueprint Ministries is a not for profit corporation. Volunteers participating in Blueprint Ministries will be expected to participate in specific construction activities including, but not limited to, demolition, roofing, carpentry, digging, plumbing, glasswork, painting, flooring, masonry, exposure to hazardous material, and other facets of construction. These activities may include, but are not limited to, the use of power tools such as saws and drills, as well as the use of hand tools. The activities may also require climbing with and without supplies, tools, and materials, as well as working in high places such as roofs, and other facets of construction work. Participants will also be involved in food preparations and service. In their free time, volunteers may choose to engage in activities including, but not limited to, sports, hiking, shopping, touring or other activities of their choosing. Blueprint Ministries may sponsor some recreational activities, which may include but are not limited to swimming, basketball, volleyball, baseball, football, and Frisbee. Other activities include, but are not limited to, travel to homes, parks, theaters, churches, restaurants, and shops. Volunteers are not required to engage in any activity in which they feel they are not able to safely participate. Photo Release: By signing below, I grant Blueprint Ministries, Inc., its representatives, and employees the right to take photographs of me and my property in connection with this ministry. I authorize Blueprint Ministries, Inc., its assigns and transferees to copyright, use, and publish the same in print and/or electronically. I agree that Blueprint Ministries, Inc. may use such photographs of me with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web content. I/We, and, parent(s) or guardian(s) of have read the foregoing statement of activities, understand the extent and nature of the activities in which my/our child/ward will participate, and herby release and discharge Operation Restoration (OR), d.b.a. Blueprint Ministries, Inc., and its officers, directors, agents, employees, volunteers, and all person connected therewith from any and all liability, claims and causes, or action of any type whatsoever arising out of or in any way connected with my/our child s/ward s participation in the activities of Operation Restoration (OR), d.b.a. Blueprint Ministries, Incorporated, on (start date) through (end date). Parent/Guardian Signature: Date: / / Parent/Guardian Printed Name: Birth: / / Relationship to Child: Phone: Address: City: State: Zip: Child s Printed Name: Birth: / / School Name: Church Name:

4 18 & Over Liability Release Statement of Activities and Release of Participation Liability Form For Blueprint Ministries Participants Aged Eighteen and Over Operation Restoration (OR), d.b.a Blueprint Ministries, Incorporated, is an inner city home repair ministry in San Antonio, Texas. Blueprint Ministries is a not for profit corporation. Volunteers participating in Blueprint Ministries will be expected to participate in specific construction activities including, but not limited to, demolition, roofing, carpentry, digging, plumbing, glasswork, painting, flooring, masonry, exposure to hazardous material, and other facets of construction. These activities may include, but are not limited to, the use of power tools such as saws and drills, as well as the use of hand tools. The activities may also require climbing with and without supplies, tools, and materials, as well as working in high places such as roofs, and other facets of construction work. Participants will also be involved in food preparations and service. In their free time, volunteers may choose to engage in activities including, but not limited to, sports, hiking, shopping, touring, or other activities of their choosing. Blueprint Ministries may sponsor some recreational activities, which may include, but are not limited to, swimming, basketball, volleyball, baseball, football, and Frisbee. Other activities include, but are not limited to, travel to homes, parks, theaters, churches, restaurants, and shops. Volunteers are not required to engage in any activity in which they feel they are not able to safely participate. Photo Release: By signing below, I grant Blueprint Ministries, Inc., its representatives, and employees the right to take photographs of me and my property in connection with this ministry. I authorize Blueprint Ministries, Inc., its assigns, and transferees to copyrights use and publish the same in print and/or electronically. I agree that Blueprint Ministries, Inc. may use such photographs of me with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising and web content. I,, have read the foregoing statement of activities in which I will participate and herby release and discharge Operation Restoration (OR), d.b.a. Blueprint Ministries, Inc., and its officers, directors, agents, employees, volunteers, and all person connected therewith from any and all liability, claims and causes, or action of any type whatsoever arising out of or in any way connected with my participation in the activities of Operation Restoration (OR), d.b.a. Blueprint Ministries, Incorporated on (start date) through (end date). This is the day of, 20. Signed: Date: / / Printed Name: Birth: / / Age: Phone: Address: City: State: Zip: Church/Organization Name:

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