2023 OIMC Mission Trip Release Form

Participants Name*

First NameLast Name

Are there any dietary issues we need to be aware of?*

Are there any medical issues/conditions or medications we need to be aware of?*

Parent/Guardian Information*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Relationship to Participant(s)?*

Emergency Contact #1*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Emergency Contact #2 (Must Be Different)*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

I, the undersigned parent or guardian, do hereby attest that all the information on this form concerning my child(ren)/dependent(s) is the most current available for my child(ren) (the “Participant(s)”). I give my permission for the Participant(s) to participate in the activities of the 2023 OIMC Mission Trip sponsored by Button Memorial UMC, The Parish of Jacksboro, and FUMC Jacksboro. This includes all sponsored activities on or off the premises of the 2023 OIMC Mission Trip sponsored by Button Memorial UMC, The Parish of Jacksboro, and FUMC Jacksboro. including any and all activities involving travel. This permission shall remain in effect until June 25th, 2023 unless terminated in writing. I authorize the 2023 OIMC Mission Trip sponsored by Button Memorial UMC, The Parish of Jacksboro, and FUMC Jacksboro ministry staff and leadership to administer the medications listed above. In order for my child(ren) to receive necessary medical treatment from medical staff and/or physicians in a medical clinic or hospital in case of illness or injury, I hereby consent to and authorize the ministry staff and leadership of the 2023 OIMC Mission Trip sponsored by Button Memorial UMC, The Parish of Jacksboro, and FUMC Jacksboro to obtain and consent to medical treatment for such illness or injury during the activity or activities of the 2023 OIMC Mission Trip sponsored by Button Memorial UMC, The Parish of Jacksboro, and FUMC Jacksboro. It is understood that this authorization and consent are given in advance of any specific diagnosis or treatment and are given to encourage those persons who have temporary custody of the Participant(s), in my absence, and medical staff to exercise their best judgment as to the requirements of such diagnosis or said medical treatment. This medical consent will remain effective until one year after the date signed unless terminated in writing. I understand that any and all medical expenses incurred are my responsibility.*

I AgreeI Do Not Agree

I hereby give my permission for the Participant(s) to be transported in any vehicle designated by any ministry staff and/or leadership designated by the 2023 OIMC Mission Trip sponsored by Button Memorial UMC, The Parish of Jacksboro, and FUMC Jacksboro, and in whose care the Participant(s) has been entrusted while attending and participating in an activity or activities of the 2023 OIMC Mission Trip sponsored by Button Memorial UMC, The Parish of Jacksboro, and FUMC Jacksboro following all Ministry Safe Guidelines.*

I AgreeI Do Not Agree

I hereby grant permission to the 2023 OIMC Mission Trip sponsored by Button Memorial UMC, The Parish of Jacksboro, and FUMC Jacksboro to use any still and/or moving image (video footage, photographs, and/or audio footage) depicting myself and/or dependents on the church’s website, social media groups, or other online and/or printed publications without further consideration. I acknowledge the the 2023 OIMC Mission Trip sponsored by Button Memorial UMC, The Parish of Jacksboro, and FUMC Jacksboro has the right to alter the photograph(s) at its discretion. I also acknowledge that the 2023 OIMC Mission Trip sponsored by Button Memorial UMC, The Parish of Jacksboro, and FUMC Jacksboro may choose not to use my or my child or dependent's photograph(s) at this time, but may do so at a later date, up to 2 years from the date of the photograph was taken. I also understand that once an image is posted on the website or other online platform, the image can be downloaded by any computer user, anywhere in the world. The Mission group commits to eliminating any identifying information including name and age from the publication. I hereby waive any right I may have to inspect and/or approve the finished product or the copy wherein my child/dependent’s likeness appears, or the use of which it may be applied. I hereby release, discharge, and agree to indemnify and hold harmless the 2023 OIMC Mission Trip sponsored by Button Memorial UMC, The Parish of Jacksboro, and FUMC Jacksboro, its officers, agents and/or designated leadership, from all claims, demands, and causes of action that I or my child/dependent have or may have by reason of this authorization or use of my child/dependent’s photographic portraits, pictures, digital images or videotapes, including any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said images or videotapes, or in processing tending towards the completion of the finished product, including, but not limited to, publication on the internet, in brochures, or any other advertisements or promotional materials.*

I AgreeI Do Not Agree

Parent of Guardian Signature*

Clear

Date*

Date