2023 KentuckyWMU Kids Adult & Student Information/ Release Forms

SECTION 2 PARTICIPANT MEDICAL INFORMATION
Date of last Tetanus Shot*
Within the last 10 years
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 INSURANCE & EMERGENCY INFORMATION
YesNo
Name of Policy Holder   First Name*   Last Name*
Birthday Of Policy Holder
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 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 following Kentucky WMU Event(s) {projectDate}
I, the undersigned, do for myself (or for and on behalf of my child under 18 years of age) give my permission to KentuckyWMU volunteer medical professional to administer any non-prescription medications deemed necessary during the KentuckyWMU Event.
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 KentuckyWMU participant and do hereby release from all claims and forever hold harmless the directors, officers, agents and employees of Kentucky Woman’s Missionary Union, Kentucky Baptist Convention ,and all partners(the city, county and the facility) 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 KentuckyWMU. 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.
Initials*
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 project/event site 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 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 KENTUCKYWMU Kids & Leader Forms

SECTION 1 PARTICIPANT INFORMATION

SECTION 2 PARTICIPANT MEDICAL INFORMATION

SECTION 3 INSURANCE & EMERGENCY INFORMATION

SECTION 6 RELEASE FORMS