2022 Adult Changers Registration & Medical/Release Form

Registration & Medical/Release Form

For Adult Kentucky Changers Projects
Statement of Purpose

An Adult Kentucky Changers project is an opportunity for adult men and women to be personally engaged in missions (learning, praying, giving, and serving) through construction-based projects which are promoted and sponsored by Kentucky Woman’s Missionary Union and partnering entities. Participation will involve some risks related to both the nature and location of the work as participants will be engaged in construction-related activities. Through Adult Kentucky Changers, participants will be engaged helping churches, religious camps, non-profit ministries, and individuals with construction related repairs and improvements.
NOTE TO PARTICIPANT: All Adult Kentucky Changers participants must complete this form. All sections must be completed for eligibility. The form must be submitted to Kentucky WMU before the participant can begin work on the project. Electronic subissions are submitted automatically upon completion of this electronic form. Registrants will receive a confirmation email. A paper version of the form is available upon request and may be submitted via mail to Adult Kentucky Changers c/o Kentucky WMU, 13420 Eastpoint Centre Dr., Louisville, KY 40223, or submitted in person upon arrival at the project.
Registration Information
Project Location/Date
Participant's Full Legal Name*

First NameLast Name
Name preferred*
Church Name:*
Church City:*
Date of Birth*

MonthDayYear
Date
Participant's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Type of Phone
Email*
example@example.com

Participant's Medical Information
Date of last Tetanus Shot*
Within the last 10 years
Generally, my health is: Excellent Good Fair Poor*
If FAIR or POOR, please explain your condition
List any medical difficulties for which you are CURRENTLY being treated*
If none, type NA
List any Medications you are CURRENTLY taking:*
If none, type NA
List any Medicines, food, or substances to which you are allergic:*
If none, type NA

Participant's Insurance Information
Medical Insurance Carrier*
Policy Number*
Personal ID #*
Family Physician*
Physician's phone number*

Area CodePhone Number
Policy is under the name of*
Emergency Contact *

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number

Authorizations & Releases
Authorization of Transportation

I fully understand that Adult Kentucky Changers participants may be transported to and from the jobsites in their own vehicles, in the vehicle of a fellow participant, or in a church-provided bus or van. All drivers will be at least 21 years old. I give my permission to be transported in one of these vehicles in the case of emergency. I release forever and hold harmless the directors, officers, agents, and employees of Adult Kentucky Changers, Kentucky WMU, all partnering entities, and all participating churches from any and all claims and demands for personal injury for myself.
Initials*
Authorization for Treatment/Release of All Claims

I, the undersigned, do for myself give my permission for an attending physician or hospital to administer medical care if deemed necessary by the Adult Kentucky Changers Project Coordinator and the physician or hospital staff during the Adult Kentucky Changers Work Project.

     I, the undersigned, do for myself give my permission to Adult Kentucky Changers volunteer medical professionals to administer any non-prescription medications deemed necessary during the Adult Kentucky Changers Work Project.

     I, the undersigned, do for myself, my heirs, executors, administrators, successors and assigns understand that secondary medical coverage in the amount of $2,500 (maximum) is provided for each Adult Kentucky Changers participant and do hereby release from all claims and forever hold harmless the directors, officers, agents and employees of Adult Kentucky Changers, Kentucky Woman’s Missionary Union, Kentucky Baptist Convention, and all partners(the camp, church, ministry, city, county, or school) from any and all claims and demands for personal injury, sickness, and death, as well as property damage and expenses, of any nature incurred by myself including claims and demands arising from criminal acts of other persons.

     I also assume personal responsibility for all medical bills in excess of the applicable medical insurance plan provided by Adult Kentucky Changers. Further, should it be necessary that I be returned home due to disciplinary action, medical reasons, or otherwise, I hereby assume responsibility for all transportation costs.
Initials*
Participant Model Release

By signing this document the participant hereby gives the Kentucky Woman’s Missionary Union, 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 any description and/or any other lawful purpose 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 the Kentucky Woman’s Missionary Union, its licensees, successors, legal representatives, and assignees, Kentucky Woman’s Missionary Union and the partners 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.
Initials*
I agree to the statements included above in this form and have intialed each one.
Participant Signature*

Clear
Participant Name*

Participant's First NameParticipant's Last Name
Witness Signature*

Clear
Witness Name*

Witness's First NameWitness's Last Name
Submitted Date*

MonthDayYear
Date

Payment

Registration $50

Adult Registration$50.00

Fee covers meals, T-shirt, participant insurance, & programming

Enter coupon

Total $0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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