Northwest Missouri Flood 2007 - FORMS

Team Registration, One Day Volunteer,

TEAM REGISTRATION FORM

Mail to: Eric Anderson, PO Box 226, Rock Port, MO 64482 or e-mail: pastor@rpumc.net

or call:  660-744-2101

Team Leader: _________________            Phone: ______________________

e-mail: _______________________

Address____________________________State: _______  Zip: _____________

Dates: _______________________

Size of team: _________________            Youth _____ Adult _____

Specific skills of team: ____________________________________

ONE DAY VOLUNTEER REGISTRATION, MEDICAL, and LIABILITY FORM

NW Missouri Disaster Response  - One Day VIM

Fill out form either in advance or on-site: e-mail to pastor@rpumc.net

Be prepare to give up to $30 for travel, lunch, and other expenses. It may not be necessary.   

Project Location: _____________________  Local Coordinator: _____________________         

   Big Lake, Craig, Agency, or Rosendale                       (if you do not know, leave blank)                       

Project Date: _____________________                                 

Name: ___________________________            Birth Date:_____________________________

Address: ______________________________ City:___________ State_____ Zip: _________

Home phone: _______________ Cell Phone: _____________ e-mail address: ____________

Occupation:________________ Employer: ________________ Phone __________________

Emergency Contact: _____________Relationship: __________ Phone __________________

Are you currently with a disaster relief organization?  ____YES    ____NO

If yes, name of organization ____________________________________________________

Special skills and/or disaster training: _____________________________________________

___________________________________________________________________________

Name of Church ___________________________________   Denomination _____________

Location of Church ______________________________________________

United Methodist: Is your church insured with UMPACT?   ____ YES   ____NO

Medical Release: I__________________________________ authorize ______________________________

                                             (UMVIM participant)                                            (another adult on trip)

If I am unable to do so, to consent to any necessary examination, anesthetic, medical diagnosis, surgery treatment and/or hospital care rendered to me under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine by the state in which he/she practices, during the duration of the trip identified below.

Home Physician______________________________ Phone  (       )_____________________

Medical Insurance Provider ____________________ Phone (       )______________________

Medications _________________________________________________________________

Name__________________________________________ Relationship _________________

Address______________________________________________ Phone  (     )____________

Other Medical Information ____________________________________________________

___________________________________________________________________________

I understand that team members must be cheerful, cooperative, flexible, and patient. I agree to cooperate with the team leader(s) concerning our life together, including daily assignments, food, lodging, and transportation and any other activities involving the team as a whole. I agree to stay with the team from the beginning to end of the trip (except as excused by the team leader), to abstain from the use of alcohol and tobacco while on the mission trip, and generally to behave in a Christian manner.

_______________________________________            ____________________________

Applicant's Signature                                                                      Date

RELEASE AND WAIVER OF LIABILITY

PLEASE READ CAREFULLY.  THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR LEGAL RIGHTS.

This Release and Waiver of Liability, executed on (date)____________, by (volunteer’s name)

_____________________________, in favor of The United Methodist Church, Volunteer in Missions

and their partner organizations such as AmeriCorp, Red Cross, other faith based groups, plus directors, officers, members and affiliates (herein referred to as “The Flood Recovery Task Force”).

I, the volunteer, desire to work as a volunteer for the Flood Recovery Task Force and engage in

activities, as coordinated by the Flood Recovery Task Force, related to being a volunteer.  I understand

that such activities may include, but not limited to tree and debris, application of blue tarps, distribution

of goods, I freely and voluntarily execute this Release under the following terms:

1.                  Release and Waiver.  I hereby release and forever discharge the Flood Recovery Task Force from any and all liability, claims and demands of whatever kind either in law or in equity, which arise or may hereafter arise from my activities with the Flood Recovery Task Force.  I understand that this Release discharges the Flood Recovery Task Force from any liability or claim that I may have against the Flood Recovery Task Force with respect to bodily injury, personal injury or property damages that may result from my activities with the Flood Recovery Task Force.  I also understand that the Flood Recovery Task Force does not assume any responsibility for or obligation to provide financial or other assistance, including but not limited to medical, health, auto or disability insurance in the event of injury or loss.

2.                  Medical Treatment.  I hereby release and forever discharge the Flood Recovery Task Force from

any claim which arises or may arise on account of first aid, treatment or any service rendered in connection with my volunteer activities with the Flood Recovery Task Force.

3.                  Assumption of Risk.  I understand that my volunteer activities may include work that is hazardous,

Including but not limited to work around power tools, heavy machinery, as well as transportation to and from the work site.  I hereby expressly assume the risk of injury or harm in the volunteer

activities.

4.                  Insurance.  I understand that the Flood Recovery Task Force does not carry or provide health,

medical, disability or auto insurance coverage for any emergency volunteer.  Each volunteer is expected and encouraged to obtain his or her own medical, health, disability and auto insurance.

5.                  Photographic Release.  I hereby grant unto the Flood Recovery Task Force all rights to any and

all photographic and video images made during my service to the Flood Recovery Task Force for

internal use or reasons of publicity.

6.                  Other.  I agree that this Release and Waiver is intended to be as broad and inclusive as permitted

by local and state laws.  I agree that in the event that any provision of this release shall be held to

be invalid by any court of competent jurisdiction, the invalidity of such provision shall not otherwise affect the remainder of the Release and Waiver, which  shall continue to be held enforceable.

Volunteer Signature ___________________________________________Date______________

Parent or Guardian Signature_______________________________________Date___________

   (for those volunteers under the age of 18)

Emergency Contact Information

Contact Person’s Name__________________________________

Relationship to Volunteer_________________________________

Contact Phone Number_____________________Secondary Number____________________