ADULT PARTICIPANT FORM

ADULT PARTICIPANT

This form should be completed by participants age 18 & above. It Includes: Participant Information, Emergency Contact, General Health History, Assumption of Risks and Agreements of Release and Indemnification
Name of Church*
Trip Leader*
IMPORTANT: This is a legal document. Please read thoroughly.

PARTICIPANT & CONTACT INFORMATION
Full Name*
Birthdate*
MM-DD-YYYY
Preferred Name*
T-Shirt Size *
Email*
example@example.com
Cell Phone*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact *

First NameLast Name
Relationship*
Cell Phone*

HEALTH INFORMATION
Please list any of the participant's dietary requirements or food allergies.*
COVID-19 POLICY
Be the Neighbor strongly recommends that youth and adult participants be fully vaccinated against COVID-19.

Be the Neighbor will follow all social distancing and/or masking guidelines recommended by local, state, and national health authorities and our Partners. We will communicate health and safety protocols to all participants, parents, and adult leaders prior to the beginning of the summer.

Due to the constantly evolving nature of the pandemic, we will determine negative test requirements and masking requirements closer to the beginning date of your trip. Please be prepared for the possibility of a negative test requirement by all participants prior to your trip and/or if any participant shows COVID-19 symptoms during your trip.

At the time of this writing, some of our Service Partners continue to require copies of vaccination records. We will let you know about your specific location requirements at the beginning of the month prior to your trip.

Be the Neighbor reserves the right to make changes to health protocols throughout the summer as dictated by the nature of the pandemic.
Please list date & type of last Covid vaccine received.*
(Initial vaccination series? Booster? Updated Booster?)
I have read the Covid-19 policy above & understand that vaccination records and/or a negative test may be required to participate in Be the Neighbor. I further understand that decisions regarding vaccination records and/or testing will be made shortly before our trip based on the nature of the pandemic at the time.*

Clear

Has participant ever been treated by a doctor for any of the following. Please answer every item.*

	Yes	No
Frequent Ear Infections
Dizzy Spells
Migraines
Convulsions or Seizures
Bone or Join Problems
Bleeding or Clotting Problems
High or Low Blood Pressure
Hepatitis
Currently Pregnant
Insect Sting Allergy
Poison Ivy Allergy
Pollen Allergy
Food Allergy
Penicillin Allergy
Asthma or Breathing Problems
Diabetes
Hypoglycemia
ADD or ADHD
Immunocompromised Disease

Please explain/give instructions for any of the above marked "yes"
Operations/Serious injuries including dates:*
Is the participant restricted from any activities?*
Does the participant have any special needs?*
Participant's Current Medications*
Date of participant's last tetanus shot*

MonthDayYear
Date

AUTHORIZATION FOR TREATMENT
Name of Participant*

First NameMiddle NameLast Name
I, the undersigned, do hereby authorize Be the Neighbor and its agents or representatives to consent, on my behalf, to any medical/hospital care or treatment (including locations outside the U.S) to be rendered upon the advice of any licensed physician.

I agree to be responsible for all necessary charges incurred by any treatment rendered pursuant to this authorization, including but not limited to hospital, doctor, ambulance, or medical fees.

I further agree that in giving this permission and authorization, Be the Neighbor does not assume any responsibility or liability for the payment of such hospital, doctor, ambulance, or other medical fees that may be incurred.

I am eighteen years of age or older, have read the above authorizations, and confirm that the information contained therein is true and accurate.
Signature of parent/guardian*

Clear
Date*

MonthDayYear

MEDICATIONS, ACTIVITIES, RISKS
ACKNOWLEDGEMENT OF INHERENT RISK WAIVER AND RELEASE
For and in consideration of the services of Be the Neighbor the undersigned acknowledges and agrees as follows:

Be the Neighbor experiences include partnering with independent social service and ministry organizations and participating in a number of activities, including but not limited to provision of direct social services, hot meal preparation, cleaning, gardening, construction, painting, repairs, and other activities specific to a particular program. The same elements that contribute to the unique character of these activities also can cause loss of or damage to personal effects, emotional trauma, or major or minor injury/illness, death, sickness or disease including COVID-19.

Participants will meet at a church facility and must be transported to and from activity sites; therefore, it will be necessary to travel by motorized vehicle on public roads. Participants are responsible for their own safety and the safety of other group members. Trip Leaders are ultimately responsible for safety throughout the event. Be the Neighbor staff may not always be present or immediately available.

I acknowledge and understand there are inherent risks associated with Be the Neighbor activities. I will assume the risk associated therewith, whether known or unknown to me at this time. I release Be the Neighbor, its employees, agents, officers, directors, and partner organizations from responsibility for accidental physical injury, including death or illness, including, without limitation, COVID-19, and loss of personal property during a be the neighbor week. I further release be the neighbor from any causes, claims, suits, liabilities, or demands of any nature whatsoever including, but in no way limited to, claims of negligence, made by myself, family, estate, heirs, personal representative or assigns, now or in the future.
Signature*

Clear
Date*

MonthDayYear
Date

PHOTO RELEASE
Please Select*
Signature*

Clear
Date*

MonthDayYear

BE THE NEIGHBOR COMMUNITY COVENANT
I will treat all other participants with respect. I understand that differences in beliefs/opinions may arise in group discussions. I will listen, seek to understand, & express my beliefs/opinions in ways that do not belittle others.

I will treat service partners & their clients respectfully by carefully listening, following instructions, & by fully engaging in the service activity. I will stay in the designated service areas at all times & will not go anywhere alone.

I will treat guest leaders with the utmost courtesy & respect by listening attentively & participating in coversation only when asked to do so by the guest leader.

I will respect the property of the host congregation by staying only in Be the Neighbor designated rooms/areas, by keeping the facility clean, by conducting myself calmly and quietly around others in the building, & by immediately reporting any accidental damage.

I will participate in all scheduled activities.

I will never leave the group without telling our Trip Leader and a Be the Neighbor staff person.

I will not use obscene or abusive language & I will not engage in reckless behavior that could cause harm to others/myself.

I will use my cell phone only during break or travel times. I will not use my cell phone during worship, program, or service activities, except in the event of an emergency.

I will not have in my possession fireworks, firearms, illegal drugs, weapons or alcohol. I understand that illegal activity will not be tolerated and that local police will be called if necessary.

I will not use or have in my possession tobacco products.

I will not engage in any sexual activity or harassment, including comments, gestures, or physical contact.

I will respect and abide by the health and safety required dress requirements of our service partners.

I will follow all masking or social distancing precautions required by our host facilities and service partners at the time of our trip.
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

ADULT PARTICIPANT

COVID-19 POLICY

ACKNOWLEDGEMENT OF INHERENT RISK WAIVER AND RELEASE