INSURANCE FORM


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Youth MEDICAL RELEASE / INSURANCE FORM Bethany United Methodist Church – Student Ministries (Austin, Texas) This release is valid from date of signature to August 31, 2019. STUDENT ________________________________________ BIRTHDATE ________________ GRADE _______ Last

First

M.

HEIGHT ______________ WEIGHT ___________ Sex __________ ADDRESS_________________________________________________________________________________ Number

Street

City

State

Zip

STUDENT CELL___________________

Student Ministries has permission to text student: Yes____ No___ FATHER/GUARDIAN NAME ________________________ PHONE: HOME____________CELL______________ MOTHER/GUARDIAN NAME _______________________ PHONE: HOME____________ CELL______________ E-Mail: Father _______________________________ Mother: _____________________________________ EMERGENCY CONTACT ______________________________________________________________________ Not a Parent

Name

Best Phone Number

Relationship

FAMILY DOCTOR_________________________________ OFFICE PHONE ______________________________ FAMILY DENTIST_________________________________ OFFICE PHONE ______________________________

Front of Medical Insurance Card

Back of Medical Insurance Card

DATE OF LAST TETANUS SHOT(required) _____________ Drug Allergies______________________________ SPECIAL HEALTH PROBLEMS __________________________________________________________________ MEDICATIONS______________________________________________________________________________ Food or other ALLERGIES ___________________________________________________________________ SWIMMING ABILITY (CHECK ONE): GOOD SWIMMER FAIR SWIMMER NON-SWIMMER This consent form gives permission to seek whatever emergency medical attention is deemed necessary, and releases Bethany United Methodist Church and its staff of any liability against personal losses of __________________________________ (student name). I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the church, its pastors, employees, agents, and volunteers workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the immediate attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event emergency treatment is required from a physician and/or hospital personnel designated by the church, I/we agree to hold such a person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date, and will, to the best of my /our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the youth ministry staff.

PARENT OR GUARDIAN SIGNATURE ________________________________ DATE ________________________________ Before me, the undersigned authority, on this day personally appeared _________________________ known to me to be the person whose name is subscribed above and acknowledged to me that she/he executed the same for the sworn purpose therein expressed. Sworn and subscribed before me this _______ day of ______________ 20___. ______________________________________ Notary Public in and the ____________ County State of Texas. My commission expires __________________ (over)

Covenant of Conduct Bethany United Methodist Church – Youth Ministries (Austin, Texas) This Covenant of Conduct is valid from date of signature to August 31, 2019. For your information, we expect each student to conform to these rules of conduct: No possession or use of alcohol, drugs, or tobacco No students can drive No fighting, weapons, fireworks, lighters, or explosives No offensive or immodest clothing No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters No inappropriate sexual behavior or excessive displays of affection Participation with the group is expected Respect property Respect one another, staff, and adult leaders Respect and comply with event schedules Respect curfews and “lights out” times set by adult leaders Will not leave event without adult permission Full participation in all activities is expected. If it is necessary for a youth to leave before an event is over, an adult leader must be notified. Full participation includes the following: Come with a positive attitude. Be courteous and show respect to everyone. Treat each other with kindness. Participate with God as your focus. Be friendly and meet new people. Have fun. Reward for Following the Covenant of Conduct: You, the other youth and adults participating in Bethany United Methodist Youth activities will have the best possible time. In addition, the Lord will be pleased and you will be blessed. Students who fail to comply with this Covenant of Conduct may be sent home at their parents’ expense. I, the student, have read the Covenant of Conduct. I agree to abide by it. Student signature: ______________________________________________________

Date: _______________

We (I) as parents (guardian) understand the Covenant of Conduct. If the youth disregards the Covenant of Conduct, a serious attempt to contact all the above phone numbers will be made and plans to pick up the Youth will be arranged. If we (I) are unavailable for contact or refuse to pick up the youth, the current most available transportation carrier will be used (at my expense) to return the youth home. Parent/guardian signature: ________________________________________________ Date: _______________

Parents and Youth, please understand that photos and video may be taken during youth events to be used in the future promotion of our ministries and programs via the internet and youth publications. (If students are identified, it will be by first name only.) If you do not want your youth’s photo to be published on the internet or in youth publications, please indicate below by checking the box.

□ I do NOT give permission to electronically display or publish a photograph or video of my youth. (over)

Forms

ALL THREE PAGES MUST BE KEPT IN THE VEHICLE IN WHICH YOU ARE TRAVELING AT ALL TIMES. This is a 3-page form and must be FULLY completed.

Medical Information Form Last Name ______________________ First __________________ MI ______ Address _______________________ City ____________ St ____ Zip _______ Phone _________________________ Occupation ______________________ *Social Security Number ___________________ Date of Birth _______________ Church _______________________________ Church Phone ______________ Church Address __________________ City _____________ St ____ Zip ______ Personal Physician _______________________ Phone ___________________ *Insurance Company ____________________ *Phone ____________________ *Policy # __________ *Insured ID # ___________ *Prescription Card # ________ In case of emergency contact: Name _____________________________ Relationship __________________ Daytime Phone ______________________ Evening Phone _________________ Name _____________________________ Relationship __________________ Daytime Phone ______________________ Evening Phone _________________ Medication(s) you cannot take _______________________________________ _____________________________________________________________ Medication you are currently taking ___________________________________ _____________________________________________________________ These medications are to be administered by (circle one):Youth / Contact Person / Staff Allergies / special health problems or concerns ____________________________ _____________________________________________________________ Do you have a current tetanus shot? Yes / No If yes, indicate date _________

If no, we encourage you to get one before you come.

*In lieu of this information, you may provide a copy of the front and back of your medical insurance card.

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Statement of Activities and Release Form Youth Service Ministry (YSM) at Mountain T.O.P. is a Christian Service ministry with the people of the Cumberland Mountains in Tennessee. Volunteers participating in the activities of this ministry will be expected to be involved in all activities and to respect the people of the Cumberland Mountains at all times. Volunteers will participate in (but will not be limited to) yard work, porch and steps repair, flat roof painting and repair, shed construction, winterization projects, painting, cleaning, insulation, window repair/replacement, and other minor home repairs as need determines and are within the capability of the volunteer service team. These activities may include the use of hand tools and the handling of materials and supplies. Power tools will only be used under the direct supervision of an adult and then only if the individual has the necessary skills to appropriately handle the power tool. Participants are never forced or required to engage in any work or activity in which they feel they are not able to participate safely. YSM participants understand that photos and video may be taken during the course of the camp week that may be used by Mountain T.O.P. in the future promotion of our ministries and programs. Participants are expected to follow all guidelines of participation, philosophies, and expectations set by the organization and camp staff. Examples of unacceptable behavior include sneaking out after lights out, violating the tobacco policy and other Mountain T.O.P. policies, going to places in the area which have been identified by camp staff as dangerous, and being disruptive to the camp life. We acknowledge that every effort has been made in preparing the participants for this mission experience. We therefore release Mountain T.O.P., Incorporated, its agents, employees, and any and all persons connected therewith from any and all liability, claims, and causes of action of any type whatsoever arising out of or in any way connected with participation in the activities of the Mountain T.O.P. mission project. Further, consent/permission is given for (participant) ____________________to be treated by competent medical personnel in the event of an accident or medical emergency and to receive reasonable medical treatment as deemed necessary by a licensed physician.

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In the event treatment is called for which a physician and/or other professional health care provider in the hospital/clinic refuses to administer without my consent, we hereby authorize: Adult Group Leader (Print full name): _______________________________________ and MTOP Camp Director (Print full name): _____________________________________ to give such consent for us in the event that we are not readily accessible by phone. If in the event it becomes necessary for either of the identified persons to give consent for us, we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from giving such consent. We understand that Mountain T.O.P. requires proof of personal insurance or acknowledgment of financial responsibility for all medical expenses. We agree that our insurance company (if applicable) will be used for all necessary medical expenses and we are aware that we may be billed by the medical provider for any medical expenses not covered by our personal insurance policy and will be responsible for payment of those expenses. This is the ______ day of _____________, 20

.

________________________________________ Signature (Participant) ________________________________________ Signature (Parent or Guardian if participant is a minor) Please circle one: I give permission to release this information to adult drivers and summer staff in order to ensure my/my youth's health issues are properly addressed. YES / NO THIS FORM MUST BE NOTARIZED for anyone under the age of 18: Subscribed and sworn to before me this _________ day of ____________, 20

.

_________________________________________ Notary Public signature My commission expires: ______________________

Notary Public seal or stamp required above

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Mountain T.O.P. Participant Skills Sheet Name:_______________________________________________ Church/School:____________________________________________________________________ Dates attending camp:________________________________ It is important to know that construction skill is never a prerequisite for participation at Mountain T.O.P. We simply have a very wide range of physical needs to meet, and we want to match your group with the most appropriate project to ensure a quality experience for you and the family you will be working with. Please honestly rate your skill/experience in the following areas. If there are multiple options beside a skill, circle all that apply. H = High – Professional: Been paid for it M = Medium - Could do it alone with little or no supervision L = Low – Would need direct supervision at beginning Z = Zero – Never even heard of it ! "#$%&!'()*+,%! -!!!!.!!!!/!!!!0! ! ! '+,+1&!2)(34,5(6!78(+*9! !

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