Adult Volunteer Registration

Adult Volunteer Registration

To be completed by Volunteer
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Birth Date

MonthDayYear
Date
Email
example@example.com
Gender

MaleFemale
Church
Shirt Size*

Insurance Company
Responsible Insured
Policy#
Group#
Emergency Contact
Name

First NameLast Name
Cell/Home Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
MEDICAL TREATMENT FORM
(Please complete entire section)
Emergency Medical Treatment Release Statement: I authorize the FMSM staff, personnel, adult volunteers and/or any licensed physician, EMT or other qualified hospital personnel to render emergency first aid and/or seek all necessarym edical attention.
Signature*

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Date

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Date
List all food allergies

PART I
Faith of a Mustard Seed Ministry, INC.
Photo Release and Consent

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I give my permission and consent, to Faith of a Mustard Seed Ministry, Inc., (herein FMSM) its officers, employees, agents, assignees, licensees, and cooperating related entities, and their representatives,
to use my likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video
recordings, audiotapes, digital images, and the like (herein pictures), for any purpose consistent with the
FMSM mission. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes,
reprints, reproductions, publications, advertisements, and any promotional or educational materials in any
medium now known or later developed, including the Internet. I release, hold harmless, and forever
discharge FMSM its officers, employees, agents, assignees, licenses, and cooperating related entities, their
representatives, heirs, and executors from any and all claims, demands, and causes of action, which I or my
heirs, executors, representatives, administrators, or any other person acting on my behalf, or on behalf of my
estate, which they have or may have by reason of this release, consent, and authorization.
PART II
Faith of a Mustard Seed Ministry, INC
Waiver of Liability and Release of Claim

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IN ORDER FOR ME TO PARTICIPATE IN THE RETREAT, ACTIVITIES, AND EVENTS, SPONSORED BY FAITH OF A MUSTARD SEED MINISTRY, INC., HEREIN CALLED “FMSM”, I HEREBY, AND FOR (MY) HEIRS, EXECUTORS, ADMINISTRATORS, AND/OR ASSIGNS, WAIVE AND RELEASE ANY AND ALL RIGHTS AND CLAIMS OF ANY NATURE THAT I MAY HAVE AGAINST FAITH OF A MUSTARD SEED MINISTRY, INC., ITS OFFICERS, EMPLOYEES, AGENTS, ASSIGNEES, LICENSEES, AND COOPERATING RELATED ENTITIES, THEIR REPRESENTATIVES, HEIRS, AND EXECUTORS. I FURTHER WAIVE AND RELEASE ANY AND ALL RIGHTS, CLAIMS, AND CAUSES OF ACTION FOR ANY AND ALL INJURIES AND/OR DAMAGES OF ANY KIND AND NATURE, INCLUDING PROPERTY DAMAGE, WHICH I MAY SUFFER FOR ANY REASON KNOWN AND/OR UNKNOWN, FORESEEN AND/OR UNFORESEEN, WHILE TAKING PART IN ANY ACTIVITIES AND/OR EVENTS CONNECTED WITH THE RETREAT INCLUDING AS THE RESULT OF THE NEGLIGENCE OF FAITH OF A MUSTARD
SEED MINISTRY, INC., ITS OFFICERS, EMPLOYEES, AGENTS, ASSIGNEES, LICENSEES, AND COOPERATING RELATED ENTITIES, THEIR REPRESENTATIVES, HEIRS, AND EXECUTORS. THIS RELEASE AND CONSENT SHALL BE BINDING UPON MY HEIRS, EXECUTORS, ADMINISTRATORS, AND/OR ASSIGNS. BY SIGNING THIS RELEASE I AFFIRM THAT I HAVE READ AND UNDERSTAND THE WAIVER OF LIABILITY AND RELEASE OF CLAIM FORM.

I have read the foregoing document in its entirety. I understand that my signature affirms that I have read,
understand and agree to the terms of the document including the Photo Release and Consent, and Waiver of
Liability and Release of Claim.
Print name
Signature*

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Date

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Date

Adult Volunteer Registration

Emergency Contact

Credit Card