2023 Student Changers Team Member

SECTION 2 TEAM MEMBER INFORMATION
Team Position*
Choose One
If "other", please specify
Position Title
Yes, I DO NOT WANT a poloNo, I WANT a polo

Please List Your Experience for the jobs selected above
Have you ever attended a Kentucky Changers Project? Yes No*
Most Recent Year attended Year* Total Years attended Total Number*
PoorFairGoodExcellent
List your experience working with teenagers*
How long have you been a Christian*
My initials below denote my understanding that participants at Kentucky Changers projects agree not to use tobacco products, alcoholic beverages, or illegal drugs; and not to possess or use any fireworks, firearms, knives (with the exception of utility knives), or weapons of any other kind during the duration of the project.
Initials*
My intials below denote my understanding that completion of this application is NOT a guarantee that I will be selected to serve as a Project Team Member. I understand I must complete the Online Sexual Abuse Prevention Training and my Background Check must be approved before I am added to my chosen Project Team
Initials*

Rows	Job Preference (1-7)
Roofing
Siding
Decks
Handicap Ramps
Door/Windows
Painting
Concrete Work

SECTION 3 ADULT MEDICAL INFORMATION
Date of last Tetanus Shot*
Within the last 10 years
ExcellentGoodFairPoor
If Fair/ Poor, please explain your condition
List any medical difficulties/ conditions 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

SECTION 3 ADULT INSURANCE & EMERGENCY INFORMATION
YesNo
Name of Policy Holder   First Name*   Last Name*
Medical Insurance Carrier Carrier Name*
Policy Number   Policy*   Personal ID   ID*
Family DoctorFirst Name*   Last Name*Doctor's Phone    Area Code*   Phone Number*
Emergency Contact First Name* Last Name*
Emergency Contact Phone Area Code* Phone Number*

SECTION 4 ADULT MEDICAL/ MODEL RELEASE FORM

Please Initial indicating that you have read and understood the authorizations and releases below. Sign and date the bottom of the form to indicate your understanding of and agreement with all statements provided.
AUTHORIZATION FOR TREATMENT/ RELEASE OF ALL CLAIMS

if I, the undersigned, do for myself give my permission for an attending physician or hospital to administer medical care deemed necessary by the KentuckyWMU Event/Project Coordinator and the physician or hospital staff during the KentuckyWMU event/ project. I, the undersigned, do for myself give my permission to KentuckyWMU volunteer medical professionals to administer any non-prescription medications deemed necessary during the KentuckyWMU Event/ 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 KentuckyWMU participant and do hereby release from all claims and forever hold harmless the directors, officers, agents and employees of Kentucky Changers, Kentucky Woman's Missionary Union, Kentucky Baptist Convention, and all partners(the venue, church, ministry, city, county, or school) from any and all claims and demands for personal injury, sickness, and death, as well asproperty 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 KentuckyWMU. 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 itlusion, 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*
AUTHORIZATION OF TRANSPORTATION

I fully understand that 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 Kentucky Changers, Kentucky WMU, all partnering entities, and all participating churches from any and all claims and demands for personal injury for myself.
Initials*
I agree to the statements included above in this form and have intialed each one. I agree that all the information in this application is true and accurate to the best of my knowledge. I understand that false information will be grounds for refusal and/ or termination of Team Member Service.
Participant Signature*

Clear
Participant Name

First NameLast Name
Date*

MonthDayYear
Date
Witness Signature

Clear
Witness Name

First NameLast Name

My Products*

2023 STUDENT Kentucky Changers Team Member Registration

Fee covers meals, polo, participant insurance, & programming (First registgration is $55, each additional is $15)

$55.00 Projects
Item subtotal:$0.00

2023 Student Changers T-shirt

Polo is included in registration price. If you would also like a t-shirt, please purchase here by clicking the box.

$10.00 Size

Enter coupon

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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2023 ADULT COMPLETE REGISTRATION

SECTION 1 PARTICIPANT INFORMATION

SECTION 2 TEAM MEMBER INFORMATION

SECTION 3 ADULT MEDICAL INFORMATION

SECTION 3 ADULT INSURANCE & EMERGENCY INFORMATION

SECTION 4 ADULT MEDICAL/ MODEL RELEASE FORM