2023 Student Changers Adult & Student Forms

2023 KENTUCKY CHANGERS (STUDENTS) STUDENTS & ADULTS COMPLETE REGISTRATION

EVENT: 2023 Kentucky Changers Projects
EVENT(S):

2023 KENTUCKY CHANGERS (STUDENTS) PROJECTS
SECTION 1 PARTICIPANT INFORMATION
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/ LEADER: All Kentucky Changers participants (students and adults) must complete this form in its entirety. Adult participants should sign the back. Students must have their parent/guardian sign it. A witness must also sign the back for the participant to be eligible to participate in a Changers work project. All sections must be completed for eligibility. A printable version of this form can be made available upon request. The form must be received by Kentucky WMU, 13420 Eastpoint Centre Dr, Louisville, KY 40223, no later than June 1.
Somerset June 24-30Mayfield
Church Name*
Adult (18+)Student
Participant's Name*

First NameLast Name
Name preferred (if different from above)
Phone Number*

Area CodePhone Number
Participant's Email*
example@example.com
T-Shirt Size*
Adult unisex
Participant's Date of Birth (MM/DD/YYYY)*

MonthDayYear
Participant's age as of day of Project*
Grade Completed as of 6/1/2023*
MaleFemale
Participant's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/ Guardian's Name

First NameLast Name
Parent/ Guardian Cell Phone Number

Area CodePhone Number

SECTION 2 PARTICIPANT MEDICAL INFORMATION
Date of last Tetanus Shot*
Within the last 10 years
ExcellentGoodFairPoor
If Fair/ Poor, please explain condition
List any medical difficulties/ conditions for which participant is CURRENTLY being treated*
If none, type NA
List any Medications participant is CURRENTLY taking:*
If none, type NA
List any Medicines, food, or substances to which participant is 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 Kentucky Changers Group Information and Work Survey

Please fill in information provided. Please mark areas of work as 1st, 2nd, and 3rd choice
Please mark choose your choices for 1st, 2nd and 3rd preferred areas of work:
1st Choice
2nd Choice
3rd Choice

SECTION 5 Kentucky Changers Responsibilities and Agreement Form

Please read through the list of responsibilities mentioned below, then sign and date the form as a pledge of your commitment to help ensure a wonderfully memorable experience for everyone. We ask that parents/ guardians sign this form as well acknowledging their minor child/ward's commitment.
During my Kentucky Changers project, I will demonstrate my love for Christ and for others by agreeing to:

1. Keep myself healthy. I agree not to use tobacco products, e-cigarettes, alcoholic beverages, and non-prescription drugs. I will notify the project nurse of any prescription drugs I will be using during the week. (This includes Adults)

2. Maintain my safety and the safety of others. I agree not to horse around at the work site because this could cause someone to be seriously or even fatally hurt. I also agree not to have possession of or use any fireworks, firearms, knives, or weapons of any other kind.

3. Follow the Kentucky Changers schedule. I understand that any schedule changes must be made by the Project Coordinator. In consideration of others and in order to receive enough rest, I will respect the lights-out time.

4. Follow the Kentucky Changers dress code. I agree to bring clothes that comply with the dress code, and not to bring clothes that do not comply with the code. I will dress abide by the dress code and dress in a manner worthy of a Christian witness.

5. Abide by the Cell Phone and Electronics Policy. I agree to only use my cell phone and other electronic devices during designated times and will turn my phone into my leader all other times.

6. Stay in designated Kentucky Changers areas. I agree to stay with the group at all times. I understand that I cannot leave the work site or home base without the permission of the Project Coordinators. I will not “aimlessly wander” inside or outside of the school building. I also agree to remain in designated areas for my gender. I understand that Boys are not permitted to be in the “FEMALES ONLY” designated area and rooms and Girls are not permitted to be in the “MALES ONLY” designated area and rooms.

7. Respect the privacy of others. I understand that others’ property and possessions must not be tampered with or taken. I expect others to grant the same measure of respect to my privacy and possessions.

8. Maintain a clean environment. I will do my best to keep all areas of the school clean and free from litter. I respect the property and grounds of the place we call “home” for the week. I understand that any damage to school property or grounds I cause will be my personal responsibility.

9. Demonstrate a Christ-like spirit. My attitude will be like that of Jesus (Philippians 2:5). I will always strive to exhibit the best attitude toward fellow workers, hosts, leadership, and the residents of the community. I will not allow or participate in abuse of another person’s property.
I understand that these responsibilities are designed to make the week a pleasant experience for all involved. If I choose not to accept these responsibilities, I forfeit my privilege of participation in Kentucky Changers and could be sent home at my own expense from the Kentucky Changers project
Participant Signature*

Clear
Participant Name

First NameLast Name
I understand that these responsibilities are designed to make the week a pleasant experience for all involved. If my minor child/ward chooses not to accept these responsibilities, I acknowledge that my child/ward forfeits his/ her privilege of participation in Kentucky Changers and could be sent home at my own expense from the Kentucky Changers project
Parent/ Guardian Signature

Clear
Parent/ Guardian Name

First NameLast Name

SECTION 6 RELEASE FORMS

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

I, the undersigned, do for myself (or for and on behalf of my child under 18 years of age) give my permission for an attending physician or hospital to administer medical care if deemed necessary by the Kentucky Changers Project Coordinator and the physician or hospital staff during the Kentucky Changers Work Project.
I, the undersigned, do for myself (or for and on behalf of my child under 18 years of age) give my permission to Kentucky Changers volunteer medical professional to administer any non-prescription medications deemed necessary during the Kentucky Changers Work Project.
I, the undersigned, do for myself, my heirs, executors, administrators, successors and assigns (or for and on behalf of my child under 18 years of age and his/her heirs, executors, administrators, successors, and assigns) understand that secondary medical coverage in the amount of $2,500 (maximum) is provided for each Kentucky Changers 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 city, county and the 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 (or my child under 18 years of age) including claims and demands arising from criminal acts of other persons.
I also assume personal responsibility for all medical bills (for myself or my child under 18 years of age) in excess of the applicable medical insurance plan provided by Kentucky Changers. Further, should it be necessary for the participant to return home due to disciplinary action, for medical reasons, or otherwise, I hereby assume responsibility for all transportation costs.
PARTICIPANT MODEL RELEASE

By signing this document I, the undersigned participant (or the parent/ guardian for and on behalf of the participant under 18 years of age), 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 the I, the undersigned participant (or the parent/ guardian for and on behalf of the participant under 18 years of age), may have to control the use to which said product, products, copy, and/or soundtrack may be applied. I, the undersigned participant (or the parent/ guardian for and on behalf of the participant under 18 years of age), 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, the undersigned participant (or the parent/ guardian for and on behalf of the participant under 18 years of age) may have in connection with said images and with the use thereof.
Initials
AUTHORIZATION OF TRANSPORTATION

I, the undersigned participant (or the parent/ guardian for and on behalf of the participant under 18 years of age), fully understand that participants may be transported to and from the jobsites by church buses, vans and personal vehicles of participating church groups. All drivers will be at least 21 years old. I, the undersigned participant (or the parent/ guardian for and on behalf of the participant under 18 years of age), authorize myself or my child/ward to be transported in one of these vehicles for project transportation or in the case of emergency. I, the undersigned participant (or the parent/ guardian for and on behalf of the participant under 18 years of age) 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 or my minor child/ ward.
Initials
I agree to the statements included above in this form and have intialed each one.
Participant Signature*

Clear
Participant Name

First NameLast Name
Parent/ Guardian Signature

Clear
Parent/ Guardian Name

First NameLast Name
Date*

MonthDayYear
Date
Witness Signature

Clear
Witness Name

First NameLast Name
Should be Empty:

2023 KENTUCKY CHANGERS (STUDENTS) STUDENTS & ADULTS COMPLETE REGISTRATION

SECTION 1 PARTICIPANT INFORMATION

SECTION 2 PARTICIPANT MEDICAL INFORMATION

SECTION 3 ADULT INSURANCE & EMERGENCY INFORMATION

SECTION 4 Kentucky Changers Group Information and Work Survey

SECTION 5 Kentucky Changers Responsibilities and Agreement Form

SECTION 6 RELEASE FORMS