Adult Volunteer Information Form For Youth Activities

Transcription

1 ugust 1, 2017-July 31, 2018 dult Volunteer nformation orm or outh ctivities (opy of your health insurance card must be attached) ull ame ell hone ate of Birth emale Male mail ddress mergency nformation: ietary or ealth estrictions octor hone # Medications taken on a daily or regular basis ist any physical or medical conditions requiring special attention llergies Medications ate of ast etanus nsurance ompany ns ompany phone # ddress olicy # Group # (ou must attach a copy of front and back of current health insurance card) (f you can be a driver we also need a copy of your driver s license and auto insurance policy) MG ame elationship ddress hone # ame elationship ddress hone #

2 dult haperone eleasemedical orm ( copy of your health insurance card must be attached.) agree being a chaperone on the outh ctivities with untsville irst nited Methodist hurch from ugust 2015-July 2016 that my signature carries with it the following: uthorization and permission is hereby given to said church to furnish any necessary transportation, food, and lodging, for me during the excursions and activities of the youth ministry program. understand all safety precautions will be taken at all times by untsville irst nited Methodist hurch and its agents during all events and activities. understand the possibility of unforeseen hazards and know the inherent possibility of risk. agree not to hold untsville irst nited Methodist hurch, its leaders, employees, andor other volunteer staff liable for damages, losses, diseases, or injuries incurred. urthermore, hereby assume all risk of personal injury, sickness, death, damage, and expense as a result of participation in recreation and work activities involved therein. understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. n the event they cannot be reached in an emergency, hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment andor to order an injection, anesthesia, or surgery for me as deemed necessary in the event that am not able to make this decision for myself due to injury, etc. understand that my insurance coverage will be used as primary coverage in the event medical intervention is needed. overage by untsville irst nited Methodist hurch can be used as a backup policy only if the accident or injury takes place on the church property. hould it be necessary for me to return home due to medical reasons, hereby assume all transportation costs. authorize photographs and video to be taken and used for present and future untsville irst nited Methodist hurch media and publications. outh Ministry dult haperone ignature ate

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4 hecked: nitial ate: nfo esk: Key ag #: V: G G G ownhill kiing ndicate kier ype ype 1 ype 2 ype 3 nowboard tance: (check one) eft oot ight oot orward orward umber of ays quipment (ne etter er Box) ast irst M.. treet ity tate Zip -mail ddress: river s ic. # tate our Weight lbs. our eight ft. in. ge arentguardian: f equipment user is a minor, verify that am the parent or guardian of the minor, and have authority to enter into this agreement on behalf of the equipment user and agree to be bound by the terms and conditions of this agreement. arentguardian s ignature: ate: cknowledgment of ersonal nformation & quipment nstructions have accurately represented the above listed information and it is true and correct. will not use any of the equipment to be provided to me during this transaction until have received instruction on its use and fully understand its use and function. agree to verify that the visual indicator settings to be recorded on this form for quipment ser s ignature: arentguardian ignature (if required): his damage waiver applies to equipment breakage only, not lost, misplaced or stolen equipment. f the damage abused, misplaced or stolen equipment shall be replaced by the renter. amage Waiver ccepted: es o : ecurity eposit s equired. lease ist our redit ard umber nd xpiration ate Below: X n the event all of the equipment listed on this form is not returned for any reason, authorize Winterplace ki esort to charge the account the following authorized nowboard: $ haped kis: $ ki Boards: $ Bibs: $50.00 Boots: $ oles: $25.00 G X hone # ( K (ot Valid Without icket) BB K (ot Valid Without icket) M K (ot Valid Without icket) QM MG K (ot Valid Without icket) BB M B KWB V# BB M B KWB V# Z oles - ength olor: yncro#: ole ength: olumn #: Visual ndicator ettings oe oe eel eel G: QM GM Welcome to K ost ffice Box 1, lat op, West Virginia ownhill kiing ndicate kier ype ype 1 ype 2 ype 3 nowboard tance: (check one) eft oot ight oot orward orward umber of ays quipment (ne etter er Box) ast irst M.. treet ity tate Zip -mail ddress: river s ic. # tate our Weight lbs. our eight ft. in. ge B ( ) - W G - W BB B KWBK B V # Z oles - engtholor: yncro #: Visual ndicator ettings ole ength: oe oe olumn #: eel eel G: : V: hecked: nitial ate: nfo esk: Key ag #: K (ot Valid Without icket) BB K (ot Valid Without icket) MG WV K (ot Valid Without icket) G K: equipment by the agreed date. understand that the binding system cannot guarantee the user s safety. n downhill skiing, the binding system will not release at all times or under all circumstances where release may prevent injury or death, nor is it possible to predict every situation in which it will release. n snowboarding, ski board use, and other sports utilizing equipment with non-release bindings, the binding system will not ordinarily release during use; these bindings are not designed to release as a result of forces generated during ordinary operation. understand that the sports of skiing, snowboarding, ski board use and other sports (collectively W ) involve inherent and other risks of J and. voluntarily agree to expressly assume all risks of injury or death that may result from these W, or which relate in any way to the use of this equipment. G M ew Winterplace imited iability ompany, ew Winterplace nc., and their affiliates, members, V ), from all liability for injury, death, property loss and damage which results from the equipment user s participation in the W for which the equipment is provided, or which is related in any way to the use of this equipment, including all liability which results from the GG of V, or any other person or cause. further agree to defend and indemnify V for any loss or damage, including any that results from claims or lawsuits for personal injury, death, and his agreement is governed by the applicable law of this state. f any provision of this agreement is determined to be unenforceable, all other provisions shall, G, V QM & B GM. quipment ser s ignature: ate: arentguardian: f equipment user is a minor, verify that am the parent or guardian of the minor, and have authority to enter into this agreement on behalf of the equipment user and agree to be bound by the terms and conditions of this agreement. arentguardian s ignature: ate: cknowledgment of ersonal nformation & quipment nstructions have accurately represented the above listed information and it is true and correct. will not use any of the equipment to be provided to me during this transaction until have received instruction on its use and fully understand its use and function. agree to verify that the visual indicator settings to be recorded on this form for quipment ser s ignature: arentguardian ignature (if required): his damage waiver applies to equipment breakage only, not lost, misplaced or stolen equipment. f the damage abused, misplaced or stolen equipment shall be replaced by the renter. amage Waiver ccepted: es o : ecurity eposit s equired. lease ist our redit ard umber nd xpiration ate Below: X n the event all of the equipment listed on this form is not returned for any reason, authorize Winterplace ki esort to charge the account the following authorized nowboard: $ haped kis: $ ki Boards: $ Bibs: $50.00 Boots: $ oles: $25.00 G X G G G G hone # ( QM & B GM accept for use the equipment listed on this form, and accept full financial responsibility for the care of the equipment while it is in my possession. will be responsible for the replacement at authorized value of any equipment rented under this form, but not returned to the shop. agree to return all rental QM GM Welcome to K ost ffice Box 1, lat op, West Virginia ownhill kiing ndicate kier ype ype 1 ype 2 ype 3 nowboard tance: (check one) eft oot ight oot orward orward umber of ays quipment (ne etter er Box) ast irst M.. treet ity tate Zip -mail ddress: river s ic. # tate our Weight lbs. our eight ft. in. ge B ( ) : V: hecked: nitial ate: K (ot Valid Without icket) BB K (ot Valid Without icket) MG WV K (ot Valid Without icket) equipment by the agreed date. understand that the binding system cannot guarantee the user s safety. n downhill skiing, the binding system will not release at all times or under all circumstances where release may prevent injury or death, nor is it possible to predict every situation in which it will release. n snowboarding, ski board use, and other sports utilizing equipment with non-release bindings, the binding system will not ordinarily release during use; these bindings are not designed to release as a result of forces generated during ordinary operation. understand that the sports of skiing, snowboarding, ski board use and other sports (collectively W ) involve inherent and other risks of J and. voluntarily agree to expressly assume all risks of injury or death that may result from these W, or which relate in any way to the use of this equipment. G M ew Winterplace imited iability ompany, ew Winterplace nc., and their affiliates, members, V ), from all liability for injury, death, property loss and damage which results from the equipment user s participation in the W for which the equipment is provided, or which is related in any way to the use of this equipment, including all liability which results from the GG of V, or any other person or cause. further agree to defend and indemnify V for any loss or damage, including any that results from claims or lawsuits for personal injury, death, and his agreement is governed by the applicable law of this state. f any provision of this agreement is determined to be unenforceable, all other provisions shall, G, V QM & B GM. quipment ser s ignature: ate: arentguardian: f equipment user is a minor, verify that am the parent or guardian of the minor, and have authority to enter into this agreement on behalf of the equipment user and agree to be bound by the terms and conditions of this agreement. arentguardian s ignature: ate: cknowledgment of ersonal nformation & quipment nstructions have accurately represented the above listed information and it is true and correct. will not use any of the equipment to be provided to me during this transaction until have received instruction on its use and fully understand its use and function. agree to verify that the visual indicator settings to be recorded on this form for quipment ser s ignature: arentguardian ignature (if required): his damage waiver applies to equipment breakage only, not lost, misplaced or stolen equipment. f the damage abused, misplaced or stolen equipment shall be replaced by the renter. amage Waiver ccepted: es o : ecurity eposit s equired. lease ist our redit ard umber nd xpiration ate Below: X n the event all of the equipment listed on this form is not returned for any reason, authorize Winterplace ki esort to charge the account the following authorized nowboard: $ haped kis: $ ki Boards: $ Bibs: $50.00 Boots: $ oles: $25.00 G X G G G G hone # ( QM & B GM accept for use the equipment listed on this form, and accept full financial responsibility for the care of the equipment while it is in my possession. will be responsible for the replacement at authorized value of any equipment rented under this form, but not returned to the shop. agree to return all rental kis: $ nowboard: $ erformance kis: $ Bibs: $50.00 Boots: $ oles: $25.00 elmets: $75.00 ownhill kiing ndicate kier ype ype 1 ype 2 ype 3 nowboard tance: (check one) eft oot ight oot orward orward umber of ays quipment (ne etter er Box) ast irst M.. treet ity tate Zip -mail ddress: river s ic. # tate our Weight lbs. our eight ft. in. ge - W G - W BB B KWBK B V # Z oles - engtholor: yncro #: Visual ndicator ettings ole ength: oe oe olumn #: eel eel G: : V: hecked: nitial ate: nfo esk: Key ag #: K (ot Valid Without icket) BB K (ot Valid Without icket) MG WV K (ot Valid Without icket) G K: V ), from all liability for injury, death, property loss and damage which results from the equipment user s participation in the W for which the equipment is provided, or which is related in any way to the use of this equipment, including all liability which results from the GG of V, or any other person or cause. further agree to defend and indemnify V for any loss or damage, including any that results from claims or lawsuits for personal injury, death, and his agreement is governed by the applicable law of this state. f any provision of this agreement is determined to be unenforceable, all other provisions shall, G, V QM & B GM. quipment ser s ignature: ate: arentguardian: f equipment user is a minor, verify that am the parent or guardian of the minor, and have authority to enter into this agreement on behalf of the equipment user and agree to be bound by the terms and conditions of this agreement. arentguardian s ignature: ate: cknowledgment of ersonal nformation & quipment nstructions have accurately represented the above listed information and it is true and correct. will not use any of the equipment to be provided to me during this transaction until have received instruction on its use and fully understand its use and function. agree to verify that the visual indicator settings to be recorded on this form for quipment ser s ignature: arentguardian ignature (if required): his damage waiver applies to equipment breakage only, not lost, misplaced or stolen equipment. f the damage abused, misplaced or stolen equipment shall be replaced by the renter. amage Waiver ccepted: es o : ecurity eposit s equired. lease ist our redit ard umber nd xpiration ate Below: X n the event all of the equipment listed on this form is not returned for any reason, authorize Winterplace ki esort to charge the account the following authorized nowboard: $ haped kis: $ ki Boards: $ Bibs: $50.00 Boots: $ oles: $25.00 G X G G G G hone # ( quipment amage nsurance ($1.00 per day) ccepted: es o his equipment damage insurance applies to equipment damage only, not lost, misplaced, or stolen equipment. f the equipment damage insurance is accepted, the rental facility will absorb the cost of repairing any damaged equipment; however, any lost, neglected, abused, misplaced, or stolen equipment shall be replaced by the renter. n the event all of the equipment listed on this form is not returned for any reason, have authorized Winterplace ki esort to charge the credit card used on the ecurity eposit section of the equipment rental agreement, the following authorized kis: $ nowboard: $ erformance kis: $ Bibs: $50.00 Boots: $ oles: $25.00 elmets: $75.00 hop opy ignatures hecked: Guest eceipt ownhill kiing ndicate kier ype ype 1 ype 2 ype 3 nowboard tance: (check one) eft oot ight oot orward orward umber of ays quipment (ne etter er Box) ast irst M.. treet ity tate Zip -mail ddress: river s ic. # tate our Weight lbs. our eight ft. in. ge - W G - W BB B KWBK B V # Z oles - engtholor: yncro #: Visual ndicator ettings ole ength: oe oe olumn #: eel eel G: : V: hecked: nitial ate: nfo esk: Key ag #: K (ot Valid Without icket) BB K (ot Valid Without icket) MG WV K (ot Valid Without icket) G K: W for which the equipment is provided, or which is related in any way to the use of this equipment, including all liability which results from the GG of V, or any other person or cause. further agree to defend and indemnify V for any loss or damage, including any that results from claims or lawsuits for personal injury, death, and his agreement is governed by the applicable law of this state. f any provision of this agreement is determined to be unenforceable, all other provisions shall, G, V QM & B GM. quipment ser s ignature: ate: arentguardian: f equipment user is a minor, verify that am the parent or guardian of the minor, and have authority to enter into this agreement on behalf of the equipment user and agree to be bound by the terms and conditions of this agreement. arentguardian s ignature: ate: cknowledgment of ersonal nformation & quipment nstructions have accurately represented the above listed information and it is true and correct. will not use any of the equipment to be provided to me during this transaction until have received instruction on its use and fully understand its use and function. agree to verify that the visual indicator settings to be recorded on this form for quipment ser s ignature: arentguardian ignature (if required): his damage waiver applies to equipment breakage only, not lost, misplaced or stolen equipment. f the damage abused, misplaced or stolen equipment shall be replaced by the renter. amage Waiver ccepted: es o : ecurity eposit s equired. lease ist our redit ard umber nd xpiration ate Below: X n the event all of the equipment listed on this form is not returned for any reason, authorize Winterplace ki esort to charge the account the following authorized nowboard: $ haped kis: $ ki Boards: $ Bibs: $50.00 Boots: $ oles: $25.00 G X G G G G hone # ( ownhill kiing ndicate kier ype ype 1 ype 2 ype 3 nowboard tance: (check one) eft oot ight oot orward orward umber of ays quipment (ne etter er Box) ast irst M.. treet ity tate Zip -mail ddress: river s ic. # tate our Weight lbs. our eight ft. in. ge - W G - W BB B KWBK B V # Z oles - engtholor: yncro #: Visual ndicator ettings ole ength: oe oe olumn #: eel eel G: : V: hecked: nitial ate: nfo esk: Key ag #: K (ot Valid Without icket) BB K (ot Valid Without icket) MG WV K (ot Valid Without icket) G K: further agree to defend and indemnify V for any loss or damage, including any that results from claims or lawsuits for personal injury, death, and his agreement is governed by the applicable law of this state. f any provision of this agreement is determined to be unenforceable, all other provisions shall, G, V QM & B GM. quipment ser s ignature: ate: arentguardian: f equipment user is a minor, verify that am the parent or guardian of the minor, and have authority to enter into this agreement on behalf of the equipment user and agree to be bound by the terms and conditions of this agreement. arentguardian s ignature: ate: cknowledgment of ersonal nformation & quipment nstructions have accurately represented the above listed information and it is true and correct. will not use any of the equipment to be provided to me during this transaction until have received instruction on its use and fully understand its use and function. agree to verify that the visual indicator settings to be recorded on this form for quipment ser s ignature: arentguardian ignature (if required): his damage waiver applies to equipment breakage only, not lost, misplaced or stolen equipment. f the damage abused, misplaced or stolen equipment shall be replaced by the renter. amage Waiver ccepted: es o : ecurity eposit s equired. lease ist our redit ard umber nd xpiration ate Below: X n the event all of the equipment listed on this form is not returned for any reason, authorize Winterplace ki esort to charge the account the following authorized nowboard: $ haped kis: $ ki Boards: $ Bibs: $50.00 Boots: $ oles: $25.00 G X G G G G hone # ( otal ental ays, G, V QM & B GM, V. B BW ( ) ownhill kiing ndicate kier ype ype 1 ype 2 ype 3 nowboard tance: (check one) eft oot ight oot orward orward umber of ays quipment (ne etter er Box) ast irst M.. treet ity tate Zip -mail ddress: river s ic. # tate our Weight lbs. our eight ft. in. ge - W G - W BB B KWBK B V # Z oles - engtholor: yncro #: Visual ndicator ettings ole ength: oe oe olumn #: eel eel G: : V: hecked: nitial ate: nfo esk: Key ag #: K (ot Valid Without icket) BB K (ot Valid Without icket) MG WV K (ot Valid Without icket) G K: V ), from all liability for injury, death, property loss and damage which results from the equipment user s participation in the W for which the equipment is provided, or which is related in any way to the use of this equipment, including all liability which results from the GG of V, or any other person or cause. further agree to defend and indemnify V for any loss or damage, including any that results from claims or lawsuits for personal injury, death, and his agreement is governed by the applicable law of this state. f any provision of this agreement is determined to be unenforceable, all other provisions shall, G, V QM & B GM. quipment ser s ignature: ate: arentguardian: f equipment user is a minor, verify that am the parent or guardian of the minor, and have authority to enter into this agreement on behalf of the equipment user and agree to be bound by the terms and conditions of this agreement. arentguardian s ignature: ate: cknowledgment of ersonal nformation & quipment nstructions have accurately represented the above listed information and it is true and correct. will not use any of the equipment to be provided to me during this transaction until have received instruction on its use and fully understand its use and function. agree to verify that the visual indicator settings to be recorded on this form for quipment ser s ignature: arentguardian ignature (if required): his damage waiver applies to equipment breakage only, not lost, misplaced or stolen equipment. f the damage abused, misplaced or stolen equipment shall be replaced by the renter. amage Waiver ccepted: es o : ecurity eposit s equired. lease ist our redit ard umber nd xpiration ate Below: X n the event all of the equipment listed on this form is not returned for any reason, authorize Winterplace ki esort to charge the account the following authorized nowboard: $ haped kis: $ ki Boards: $ Bibs: $50.00 Boots: $ oles: $25.00 G X G G G G hone # ( ownhill kiing ndicate kier ype ype 1 ype 2 ype 3 nowboard tance: (check one) eft oot ight oot orward orward umber of ays quipment (ne etter er Box) ast irst M.. treet ity tate Zip -mail ddress: river s ic. # tate our Weight lbs. our eight ft. in. ge - W G - W BB B KWBK B V # Z oles - engtholor: yncro #: Visual ndicator ettings ole ength: oe oe olumn #: eel eel G: : V: hecked: nitial ate: nfo esk: Key ag #: K (ot Valid Without icket) BB K (ot Valid Without icket) MG WV K (ot Valid Without icket) G K: G M ew Winterplace imited iability ompany, ew Winterplace nc., and their affiliates, members, V ), from all liability for injury, death, property loss and damage which results from the equipment user s participation in the W for which the equipment is provided, or which is related in any way to the use of this equipment, including all liability which results from the GG of V, or any other person or cause. further agree to defend and indemnify V for any loss or damage, including any that results from claims or lawsuits for personal injury, death, and his agreement is governed by the applicable law of this state. f any provision of this agreement is determined to be unenforceable, all other provisions shall, G, V QM & B GM. quipment ser s ignature: ate: arentguardian: f equipment user is a minor, verify that am the parent or guardian of the minor, and have authority to enter into this agreement on behalf of the equipment user and agree to be bound by the terms and conditions of this agreement. arentguardian s ignature: ate: cknowledgment of ersonal nformation & quipment nstructions have accurately represented the above listed information and it is true and correct. will not use any of the equipment to be provided to me during this transaction until have received instruction on its use and fully understand its use and function. agree to verify that the visual indicator settings to be recorded on this form for quipment ser s ignature: arentguardian ignature (if required): his damage waiver applies to equipment breakage only, not lost, misplaced or stolen equipment. f the damage abused, misplaced or stolen equipment shall be replaced by the renter. amage Waiver ccepted: es o : ecurity eposit s equired. lease ist our redit ard umber nd xpiration ate Below: X n the event all of the equipment listed on this form is not returned for any reason, authorize Winterplace ki esort to charge the account the following authorized nowboard: $ haped kis: $ ki Boards: $ Bibs: $50.00 Boots: $ oles: $25.00 G X G G G G hone # ( cknowledgement of ersonal nformation & quipment nstructions have accurately represented the above listed information and it is true and correct. will not use any of the equipment to be provided to me during this transaction until have received instruction on its use and function. agree to verify that the visual indicator settings to be recorded on this form for downhill ski equipment agree with the number appearing in the visual indicator windows of the equipment to be listed on this form. QM GM ndicate kier ype ( 1, 2, or 3 ) ate: ate: ft. in. ge hoe ize

5 QM & B GM accept for use the equipment listed on this form, and accept full financial responsibility for the care of the equipment while it is in my possession. will be responsible for the replacement at full value of any equipment rented under this form, but not returned to the rental facility. agree to return all rental equipment by the agreed date. understand that the binding system cannot guarantee the user s safety. n downhill skiing, the binding system will not release at all times or under all circumstances where release may prevent injury or death, nor is it possible to predict every situation in which it will release. n snowboarding, and other sports utilizing equipment with non-release bindings, the binding system will not ordinarily release during use; these bindings are not designed to release as a result of forces generated during ordinary operation. understand that the sports of skiing, snowboarding, and other sports (collectively W ) involve inherent and other risks of J and. voluntarily agree to expressly assume all risks of injury or death that may result from these W, or which relate in any way to the use of this equipment. understand that a helmet designed for W use may help reduce the risk of some types of injuries to the user at slower speeds. recognize that serious injury or death can result from both low and high energy impacts, even when helmet is worn. G M ew Winterplace imited iability ompany, ew Winterplace nc., and their affiliates, members, shareholders, directors, officers, employees, agents, and the equipment manufacturers and distributors and their successors in interest (collectively V ), from all liability for injury, death, property loss and damage which results from the equipment user s participation in the W for which the equipment is provided, or which is related in any way to the use of this equipment, including all liability which results from the GG of V, or any other person or cause. further agree to defend and indemnify V for any loss or damage, including any that results from claims or lawsuits for personal injury, death, and his agreement is governed by the applicable law of this state. f any provision of this agreement is determined to be unenforceable, all other provisions shall What type of skier are you? etermining your K is your responsibility! our skier type, height, weight, age, and ski boot sole length are used by the shop to determine the visual indicator settings of your ski bindings. Be sure to provide accurate information, as any error may increase your risk of injury. onsult these descriptions to select your classification: 1 autious skiing at W visual indicator settings refer slow to moderate speeds. refer gentle to moderate terrain. eceive lower than average visual indicator settings. his may increase the risk of inadvertent binding release in order to increase the likelihood of release in a fall. ype 1 settings apply to entrylevel skiers uncertain of their classification. 2 Moderate skiing at VG visual indicator settings refer a variety of speeds. refer a varied terrain. ype 2 skiers are skiers who do not meet all the descriptions of ype 1 or ype 3 skier types. 3 ggressive skiing at G visual indicator settings refer fast speeds. refer steep terrain. eceive higher than average visual indicator settings. his may reduce the likelihood of release in a fall in order to decrease the risk of inadvertent binding release. nce you determine what type of skier you are, indicate it on the front page of this agreement in the ndicate kier ype section. f from experience, you have been dissatisfied with visual indicator settings resulting from your selected skier type classification, you may wish to consider: (a) changing your skier type classification; (b) selecting different skier type classifications for toe and heel components; (c) selecting skier ypes -1 ( for skiers who desire visual indicator settings lower than settings for a type 1 skier ) or 3+ ( for skiers who desire visual indicator settings higher than settings for a ype 3 skier ). hese descriptions are compatible with M and ocuments. B 1. lways stay in control. 2. eople ahead of you have the right of way. 3. top in a safe place for you and others. 4. Whenever starting downhill or merging, look uphill and yield. 5. se devices to help prevent runaway equipment. 6. bserve signs and warnings, and keep off closed trails. 7. Know how to use the lifts safely. Be safety conscious and know the code. B. have read and agree to the terms of this agreement and have signed on the front of this form. oll ree W (7669) or visit us on the web: winterplace.com