Home » 2021 MSMT – Student Registration
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 minor child shall not terminate on my physical or mental disability subsequent to the date of execution hereof. This consent is only effective during the duration of the ACTIVITIES with WCUMC.
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.
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 hereby release, waive, discharge, and covenant not to sue White’s Chapel United Methodist Church (hereinafter WCUMC), their trustees, agents, servants, or employees (hereinafter referred to as releasees) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or any of the property belonging to me, whether caused by the negligence of the releasees, or otherwise, while participating in such activity, or while in, on, or upon the premises where the activity is being conducted.
I am fully aware of the risks involved and hazards connected with participating in WCUMC event, including but not limited to loss of personal property, damage, injury, including death and I hereby elect to voluntarily participate in said activity with full knowledge that said activity may be hazardous to me and my property. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death, that may be sustained by me or any loss or damage to property owned by me, as a result of being engaged in such an activity, whether caused by the negligence of releasees or otherwise.
I further hereby agree to indemnify and hold harmless the releasees from any loss, liability, damage or costs, including court costs and attorney fees, that they may incur due to my participation in said activity, whether caused by negligence of releasees or otherwise.
It is my express intent that this Waiver of Liability and Hold Harmless Agreement shall bind the members of my family, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a release, waiver, discharge and covenant not to sue the above-named releasees. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Texas.
In signing this release, I acknowledge and represent that I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed, no oral representations, statements, or inducements, apart from the foregoing written agreement, have been make; I am at least eighteen (18) years of age or guardian of a participant under the eighteen (18) years of age, and fully competent; and I execute this release for full, adequate and complete consideration fully intending to be bound by same.
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.
PLEASE READ THIS DOCUMENT CAREFULLY. BY SIGNING, YOU ARE GIVING UP LEGAL RIGHTS As a condition of anyone’s entry and presence on the Lodging Premises, Worksite, and/or any other location on a Heartwork Missions Trip and in consideration for anyone’s use of the Premises facilities or equipment or for anyone’s participation of any activities at the Premises and at the Worksites, Participant knowingly, freely, and voluntarily enters into this Release and Indemnification Agreement. This Release and Indemnification Agreement (Agreement) is entered into by the Participant, and if any minor is named below, the Adult Participant on behalf of and as parent or legal guardian for the Child Participant(s) in favor of Heartwork Missions. Collectively and severally, Adult Participant and Child Participant are referred to as the Participant. In consideration of Heartwork Missions permitting Participant access to the Premises and the ability to participate in the Activities, including the Activities that may occur in, about, or near the designated mission trip location, or any other premises owned or operated by Heartwork Missions wherever located (Premises), Participant agrees as follows: exposure to bacteria, fungus, viruses and unknown contagious diseases. By entering the Premises or when engaging in the Activities, there is a risk of exposure to bacteria, fungus, viruses, unknown contagious diseases and COVID-19, which notwithstanding governmental recommendations and the practices of Heartwork Missions, cannot be eliminated. CONSEQUENTLY, TO THE FULLEST EXTENT PERMITTED BY LAW, PARTICIPANT KNOWINGLY AND FULLY ASSUMES THE RISK OF, RELEASES, AND SHALL INDEMNIFY Heartwork Missions FROM ALL OR BODILY INJURY RESULTING FROM PARTICIPANT’S EXPOSURE TO ANY BACTERIA, FUNGUS, VIRUS, UNKNOWN CONTAGIOUS DISEASES OR COVID-19 AND IN ANY WAY CONNECTED TO PARTICIPANT’S ENTRY INTO THE PREMISES OR ENGAGEMENT IN THE ACTIVITIES. FURTHER, ADULT PARTICIPANT ON BEHALF OF HIM/HERSELF AND THAT OF THE CHILD PARTICIPANT(S) CONSENTS TO HAVING THEIR TEMPERATURE TAKEN BY HEARTWORK MISSIONS AND ACKNOWLEDGES THEY MAY BE DENIED ACCESS TO OR FORCED TO VACATE THE PREMISES IF THEY EVIDENCE SYMPTOMS OF EXPOSURE TO BACTERIA, FUNGUS, VIRUSES, UNKNOWN CONTAGIOUS DISEASES OR COVID-19 AS IDENTIFIED BY THE CENTER FOR DISEASE CONTROL AND PREVENTION.
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.
