2025 OIMC Mission Trip Release Form
Button Memorial UMC, Christ's Foundry UMC, Decatur FUMC, and FUMC Jacksboro
REGISTRATION ENDS APRIL 30th
(This includes deposit)
A $20 Non-Refundable Deposit is required before your registration will be complete. (Please make a check payable to FUMC Jacksboro or visit FUMC Jacksboro's online giving portal to make your deposit. Send Rev. Meliss Hatch or Rev. Chad Johnson a copy of your check or online payment to secure your registration).
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Yes, I am aware and prepared to make a non-refundable deposit.
PARTICIPANT INFORMATION
Participants Name
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First Name
Last Name
Are there any dietary issues we need to be aware of?
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Are there any medical issues/conditions or medications we need to be aware of?
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Preferred T-Shirt Size
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Please Select
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult 2XL
Adult 3XL
Adult 4XL
PARENT/GUARDIAN INFORMATION
Parent/Guardian Information (If over 18 put "self")
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Participant? (If over 18 put "self")
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EMERGENCY CONTACT INFORMATION
Emergency Contact #1 (Must Have for Adults and Youth)
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Emergency Contact #2 (Must Be Different)
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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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 2025 OIMC Mission Trip sponsored by Button Memorial UMC, Christ's Foundry UMC, Decatur FUMC, and FUMC Jacksboro. This includes all sponsored activities on or off the premises of the 2025 OIMC Mission Trip sponsored by Button Memorial UMC, Christ's Foundry UMC, Decatur FUMC, and FUMC Jacksboro, including any and all activities involving travel. This permission shall remain in effect until June 24th, 2025 unless terminated in writing. I authorize the 2024 OIMC Mission Trip sponsored by Button Memorial UMC, Christ's Foundry UMC, Decatur FUMC, 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 2025 OIMC Mission Trip sponsored by Button Memorial UMC, Christ's Foundry UMC, Decatur FUMC, and FUMC Jacksboro to obtain and consent to medical treatment for such illness or injury during the activity or activities of the 2025 OIMC Mission Trip sponsored by Button Memorial UMC, Christ's Foundry UMC, Decatur FUMC, 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 June 24th, 2025 unless terminated in writing. I understand that any and all medical expenses incurred are my responsibility. (If an adult please consent for yourself)
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I Agree
I 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 2025 OIMC Mission Trip sponsored by Button Memorial UMC, Christ's Foundry UMC, Decatur FUMC, and FUMC Jacksboro, and in whose care the Participant(s) has been entrusted while attending and participating in an activity or activities of the 2025 OIMC Mission Trip sponsored by Button Memorial UMC, Christ's Foundry UMC, Decatur FUMC, and FUMC Jacksboro following all Ministry Safe Guidelines. (If an adult please consent for yourself)
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I Agree
I Do Not Agree
I hereby grant permission to the 2025 OIMC Mission Trip sponsored by Button Memorial UMC, Christ's Foundry UMC, Decatur FUMC, 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 2025 OIMC Mission Trip sponsored by Button Memorial UMC, Christ's Foundry UMC, Decatur FUMC, and FUMC Jacksboro, TX has the right to alter the photograph(s) at its discretion. I also acknowledge that the 2025 OIMC Mission Trip sponsored by Button Memorial UMC, Christ's Foundry UMC, Decatur FUMC, 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 2025 OIMC Mission Trip sponsored by Button Memorial UMC, Christ's Foundry UMC, Decatur FUMC, 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.
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I Agree
I Do Not Agree
As a member of the 2025 OIMC Mission Team I agree to the following Code of Conduct while on the 2025 OIMC Mission Trip.
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I Agree
I Do Not Agree
2025 OIMC Mission Trip Code of Conduct applies to all participants (Youth and Adult) and is expected to be upheld at all times during the Mission Trip. Please agree to each section of the Code of Conduct (Youth and Adults)
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Please list any mission/work experience that can be used on the trip or areas of interest for the work sites.
Parent of Guardian Signature (If over 18 please sign for yourself)
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Date
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Month
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Day
Year
Date
Submit
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