OMP BUILD DAY Participant Sign Up

OMP BUILD DAY Participant Sign Up

Complete this form to officially sign up for one of our upcoming community Build Days! Siblings/families with the same information can use the same form to sign up. If you would like to serve with a friend, there is a space on this form to make that request.
PARTICIPANT INFORMATION
Who are you signing up for the build day?

1 Youth (6th-12th grade)More than 1 youth (6th-12th grade)Adult (18 or older)Youth and Adult
Please select which upcoming build you would like to participate in:
What service commitment would you like to make?*

Full Day (9 AM - 3 PM)Morning (9 AM - 12 PM)Afternoon (12 PM - 3 PM)
Participant Information (Please add all participants in the family, youth and adult)*
Participant Name*

First NameMiddle NameLast Name
Participant Phone Number*

Area CodePhone Number
Participant Date of Birth*

MonthDayYear
Date
Best Contact Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you volunteered with Ozark Mission Project before?
Is there anyone that is also signing up that you would like to serve with?
SECTION A. EMERGENCY CONTACT INFORMATION
OMP requires some basic contact and medical information. This information will not be shared unless medical treatment is saught.
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Phone Number*

Area CodePhone Number
Alternative contact if Emergency Contact cannot be reached*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
SECTION B. MEDICAL INFORMATION AND TREATMENT

During an OMP Pop-Up, OMP will have staff and/or volunteers available to assist you. These individuals will make arrangements for treatment of any illness or accident that might occur during the course of the project. In the case of a more serious illness or accident, the emergency contact will be contacted as soon as possible. If the situation warrants immediate attention, you may be taken to the nearest medical treatment facility in order to ensure that you can receive needed medical treatment.
Insurance Provider*
Name on Policy*

First NameLast Name
Policy/Group Number*
Is there anything OMP would need to be aware of in case of emergency? Medications, allergies, Epi-pen, etc?*
SECTION C. CONDUCT WHILE AT OMP BUILD

Participants will not possess or use alcoholic beverages, tobacco, smoking or vaping devices, illegal drugs, and firearms/weapons. Participants will be solely responsible for your clothing, jewelry, cell phones, or other personal possessions, and OMP, its staff, and volunteers shall bear no responsibility if such items are lost, stolen, or damaged.

Participants are expected to be on their best behavior, show respect towards others as well as themselves, and follow all OMP rules and other lawful instructions. Conduct which disturbs others, is improper, or is otherwise dangerous will not be tolerated and may, in the sole discretion of OMP, result in the dismissal of a participant.
SECTION D. TERMS AND CONDITIONS/PERMISSIONS/RELEASE
By signing this Information and Release Form I hereby:
1. Attendance and Participation. Grant permission for myself to attend OMP Event and certify that I am physically capable of participating in the OMP program subject to the special medical restrictions listed above.
2. Damages Caused by Participant. Agree to be financially responsible for any needed repairs resulting from any damage caused by me while at OMP Event.
3. Medical Treatment. (i) Authorize OMP, its staff, and/or volunteers to seek medical treatment for myself for any injury or illness incurred during OMP Event, (ii) grant permission for any physician to examine and treat, hospitalize, or secure treatment for myself in the event of an emergency, and (iii) agree to be solely responsible for the cost of any and all medical treatment (and medication) received by me.
4. Assumption of Risk. Acknowledge and understand that participation in OMP Event may carry the possibility of physical illness, injury, death, and/or property damage and that I, on behalf of myself, my family members, assume the risk of such illness, injury, death and/or property damage by allowing myself to participate in an OMP event.
5. Waiver, Release, Discharge, and Hold Harmless. (i) Agree on behalf of myself and my family members, to waive, release, discharge, and hold harmless OMP and any related agency, conference, district, local church, church member or attendee, employee, volunteer, or agent of OMP, from any and all liability, actions, causes of actions, claims or demands for personal illness or injury, death or property damage of any kind or nature, and any other claims whatsoever arising out of, or in any way connected with my participation in OMP Event, (ii) Understand this waiver, release, discharge and hold harmless shall extend to all claims of every kind or nature whatsoever, foreseen or unforeseen, known or unknown, and (iii) Acknowledge that this waiver, release, discharge and hold harmless shall serve as an assumption of risk, waiver, release, discharge and hold harmless for myself, my family, and our heirs, executors, administrators, guardians or anyone else who might assert a claim on myself.
6. Use of Image. Consent to OMP staff and/or volunteers taking photographs, movies, or videotapes of me for OMP purposes. This consent also includes the right to edit, use and reuse said products for any and all OMP purposes, including but not limited to educational and ministry services, and advertising or marketing efforts, and release any and all rights, title, and interest I may have in said photographs, movies, videos, finished pictures, reproductions, copies or negatives of the same in connection with such uses.
7. Dispute Resolution. This Release Form shall be governed by and construed in accordance with the laws of the State of Arkansas exclusively, and any and all claims arising from and/or related to this agreement may only be brought in a state court located in Pulaski County, Arkansas.
BY SIGNING BELOW, I give permission for the youth/myself named above to participate in all programs and activities of OMP. In consideration for allowing the participation of my youth/myself in all programs and activities of OMP, I hereby consent to this form, including any Release of Liability above, on behalf of my youth/myself, and agree that this form shall be binding upon my youth, me, my family, heirs, legal representatives, successors, and assigns. If a youth is listed above, I represent that I am the parent or legal guardian of the child listed above, who is under 18 years of age. I have read the above form and am fully familiar with the contents thereof.
Parent/Guardian Signature (if under 18) or Participant Signature

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