MINOR PARTICIPANT RELEASE

SHORT TERM MISSION TRIP: MINOR PARTICIPANT RELEASE FORM
NOTE: All Short Term Mission Trip participants and leadership must complete this form and have it notarized to be eligible to participate in a Kelly Green Global mission trip. Minors must have the signature of a parent or guardian. This form includes a medical release and model release.
ALL SECTIONS MUST BE COMPLETED AND FORM NOTORIZED FOR PARTICIPATION.
PARTICIPANT INFORMATION:
Full Name

First NameMiddle NameLast Name
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth:

MonthDayYear
Phone Number

Area CodePhone Number
Gender:

MaleFemale
Church Home:
Emergency Contact Name & Phone:
MEDICAL PROFILE
Generally, my health is (check one)

ExcellentGoodFairPoor
If FAIR or POOR, please explain your condition:
List any medical difficulties for which you are CURRENTLY being treated:
List any medications you are CURRENTLY taking:
List any medicines or substances to which you are ALLERGIC:
Family Physician:
Physician's Address
Physician's Phone:
Insurance:
Subscriber's Name:
Address:
Insurance Phone Number:
Policy Number:
Group Number:
Subscribers Employer:
Subscribers SS #:

AUTHORIZATION FOR TREATMENT
I, the undersigned, do for myself (and for and on behalf of my child under 18 years of age) give permission for an attending physician or hospital/ medical facility staff to administer medical care if deemed necessary by the Kelly Green Global leadership and/or the treating physician or hospital staff during the short term mission trip, without additional permission from the undersigned. I also assume personal responsibility for all medical bills (for myself or for my child under 18 years of age) and do certify that I have secured primary medical insurance (for myself or for my child under 18 years of age). Further, should it be necessary for me (or my child under 18 years of age) to return home due to medical reasons, for disciplinary action, or otherwise, I hereby assume responsibility for all transportation costs.
PLEASE READ AND THEN SELECT:*

By checking this box, I agree to authorization for treatment.
RELEASE OF ALL CLAIMS
I, the undersigned, do for myself (and for and on behalf of my child under 18 years of age) hereby release, indemnify and forever hold harmless the officers, directors, employees, and agents of Kelly Green Global from any and all claims, demands and causes of action for personal injury, sickness and death, as well as property damage and expenses of any nature incurred by myself (or my child under 18 years of age) including, without limitation, all personal injury, sickness, death, property damage and expenses arising out of the negligence of participant. I FULLY UNDERSTAND AND AGREE THAT THIS PROJECT REQUIRES THAT PARTICIPANTS BE WILLING TO ACTIVELY SHARE THE GOSPEL OF JESUS CHRIST BY REASONABLE MEANS AND I AGREE THAT I AM ABLE TO MEET THE PHYSICAL REQUIREMENTS THIS WILL ENTAIL.
PLEASE READ AND THEN SELECT:*

By checking this box, I agree to the release of all claims.
PHOTOGRAPHIC AND REPROGRAPHIC RELEASE
By signing this document the participant hereby gives Kelly Green Global, its licensees, successors, legal representatives and assigns, the absolute and irrevocable right and permission to use the participant’s name and to use, reproduce, edit, exhibit, project, display, copyright, publish photographic images and/or moving pictures and/or videotaped images of the participant with or without the participant’s voice, or in which the participant may be included in whole or in part, photographed, taped, videotaped, and/or recorded during the duration of the project, and therefore to circulate the same in all forms and media for art, advertising, trade, competition, of every description and/or any lawful purpose whatsoever. The participant also consents to the use of any printed matter in conjunction therewith. The participant also waives any right to inspect and/or approve the finished product or products or the editorial, promotional or printed copy or soundtrack that may be used in connection therewith and any right that I may have to control the use to which said product, products, copy and/or soundtrack may be applied. The participant discharges and agrees to save harmless Kelly Green Global, its licensees, successors, legal representatives and assigns from any liability by virtue of any blurring, distortion, alteration, optical illusion or use in composite form whether intentional or otherwise, that may occur or to be produced in the making, processing, duplication, projecting or displaying of said images, and from liability for violation of any personal or proprietary right that I may have in connection with said images and with the use thereof.
PLEASE READ AND THEN SELECT:*

By checking this box, I release my rights to photographs and videos taken of me while on this trip.
(Youth 18 & under requires parent/custodial signatures)

Each person signing below acknowledges having read this release and understanding all of its terms and their significance, and states that this release is signed and delivered voluntarily.

Participant’s Signature ___________________ __________ Date:          / /

Father/ Custodial Parent Signature ________________________ Phone (    )____________

Date ___/___/___

Mother/ Custodial Parent Signature _________________________ Phone (    )__________

Date ___/___/___

NOTARY PUBLIC

On this              day of                          of the year                    , personally appeared before

                                                     personally know by me, and in my presence executed the within and

foregoing permission and release form.

Witness my hand and official seal this                  day of              of the year                    .

My commission expires:

Notary Public

Kelly Green Global * PO Box 949 * Brandon * Florida * 33511

www.kellygreenglobal.com

info@kellygreenglobal.com
PLEASE PRINT FORM, SIGN IT AND HAVE IT NOTARIZED. THANK YOU.
Should be Empty:

SHORT TERM MISSION TRIP: MINOR PARTICIPANT RELEASE FORM

ALL SECTIONS MUST BE COMPLETED AND FORM NOTORIZED FOR PARTICIPATION.

PARTICIPANT INFORMATION:

MEDICAL PROFILE

AUTHORIZATION FOR TREATMENT

RELEASE OF ALL CLAIMS

PHOTOGRAPHIC AND REPROGRAPHIC RELEASE

(Youth 18 & under requires parent/custodial signatures)

Each person signing below acknowledges having read this release and understanding all of its terms and their significance, and states that this release is signed and delivered voluntarily.

NOTARY PUBLIC