2022 HSMT - Adult Registration - White’s Chapel UMC

1Participant Info

2Medical Info and Release

3Code of Conduct

4Leadership Experience

5Review and Submit

Participant Information
Participant's Name*
First Last
Date of Birth*
Month
Day
Year
Gender*
- Male
- Female
T-Shirt Size*
Address*
Street Address Address Line 2 City State ZIP Code
Participant's Email*
Participant's Cell*
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.

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Medical Information
Is participant currently taking prescription medicine?*
- Yes
- No
If Yes, please list medication name, dosage and frequency.*
Does the participant have any medical conditions that WC Students need to know about?*
- Yes
- No
If Yes, please list them and give symptoms.*
Does the participant have any allergies? [food, medications, etc.]*
- Yes
- No
If yes, please list them and give symptoms.*
*Please indicate if any of the participant's allergies are 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):
Month
Day
Year
Name of Physician*
Physician's Phone*
Group or Family Hospitalization Insurance Company*
Insurance Company’s Address
Group #*
Policy #*
Phone #*
In case of emergency call*
at*
White’s Chapel United Methodist Church Waiver of Liability and Hold Harmless Agreement
Hidden
Participant’s Legal Name*
Hidden
Participant's Name*
Hidden
City*
Release (required for all participating minors and adult sponsors)

I,(Participant), city of , State of Texas, hereby affirm that (I, ) 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.
Participant Signature*
Participant Name*
Date*
Month
Day
Year

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 safety by not leaving the lodging campus without a WC Student staff approval. 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 any tobacco products at the work site, at the lodging facility, and in the neighborhoods I serve in. I UNDERSTAND THAT IT IS ILLEGAL TO USE ANY TOBACCO PRODUCTS ON SCHOOL GROUNDS.

I will recognize and submit to the authority of the College/University 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, 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 adult volunteer 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 MISSION TRIP AND I MAY BE ASKED TO LEAVE (WITHOUT REIMBURSEMENT AND AT MY OWN EXPENSE) AT THE REQUEST OF THE WC STUDENTS STAFF.
Participant Signature*
Participant Name*
Date*
Month
Day
Year

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

2022 High School Mission Trip - Adult

Participant Information

Medical Information

White’s Chapel United Methodist Church Waiver of Liability and Hold Harmless Agreement

CODE OF CONDUCT

Leadership Experience