Mission Outreach – Volunteer Registration

21Dec
To be completed by each participant and submitted by May 15, 2022.
Mission Outreach - Volunteer Registration
MISSION OUTREACH - VOLUNTEER REGISTRATION
Participated with HRLC before?
Address
Address
City
State/Province
Zip/Postal
Can you receive text messages on this phone?

EMERGENCY MEDICAL INFORMATION
Medical information on this form will remain confidential and will only be used if medical treatment is needed. It will be used for no
other purpose.

Have you had a Tetanus shot?
If yes, how recent?
If this does not apply, please type in 'none'
If this does not apply, please type in 'none'
If this does not apply, please type in 'none'
MEDIA RELEASE
I hereby grant permission to Hinton Rural Life Center to use photographs, videos, social media posts, and/or any other media of me/my dependent for promotion and publicity purposes. Permission is granted for the use requested.

**If permission is not granted, it is the responsibility of the Group Leader to inform Hinton staff verbally upon arrival.

***IF VOLUNTEER IS UNDER 18 YEARS OF AGE:

Also at Hinton?
Also at Hinton?

PLEASE BRING A COPY OF YOUR INSURANCE CARD WITH THIS DOCUMENT AND KEEP A COPY OF THIS FORM IN THE VEHICLE WITH THE PARTICIPANT AT ALL TIMES.

Mission Outreach – Individual Medical Liability

21Dec
To be completed by each participant and submitted by May 15, 2022.
Mission Outreach - Individual Medical Liability
MISSION OUTREACH VOLUNTEER
CONSENT/MEDICAL CARE—AUTHORIZATION and RELEASE
(TYPE IN FULL LEGAL NAME)

I, the undersigned, hereby affirm to Hinton Rural Life Center, Inc. (hereinafter Hinton) that I hereby register to attend and participate in the mission trip to Hinton, located in Hayesville, N.C.

AUTHORIZATION FOR MEDICAL CARE
In the event that a medical emergency befalls me during the mission trip, wherein I am unable to communicate regarding which medical facility/physician/dentist to be used and to consent to medical/dental treatment, I hereby direct that Hinton attempt to contact the following adult person(s) and that Hinton follow direction given by said person(s), regarding matters in the paragraph above.

In the event Hinton is unable to contact the individuals named above for direction/consent within sufficient time as determined by Hinton, or if the physician/dentist does not deem said person(s) named above legally capable of consenting to medical/dental treatment, I hereby authorize Hinton, its officers, employees, and agents: to select a medical facility/physician/dentist and to cause me to be transported to same and to consent to medical/dental treatment as recommended by the physician/dentist including but not limited to administration of anesthesia, diagnostic medical procedures and testing, performance of operations, and other actions, but not including withdrawing or withholding life support.

RELEASE

I acknowledge that I will be participating in mission activities including but not limited to: traveling in vehicles; home repair and rehabilitation (such as general carpentry, use of electric powered tools and hand tools, painting, climbing ladders with and without supplies, working in high places, and other construction related activities); recreational activities (such as swimming, team and individual sports, etc.); residing in Hinton facilities; dining at Hinton facilities.

I acknowledge that I have read and understand the contents of the Hinton Center Sensitivity Guidelines and that copies of same have been provided to me by the mission trip group sponsor.

I acknowledge that Hinton does not provide any medical insurance coverage for mission trip participants and that I am fully responsible for medical insurance/medical care payment for myself.

I acknowledge that Hinton is a nonprofit entity which provides facilities and mission work opportunities for religious and charitable purposes.

THEREFORE, in consideration of Hinton providing facilities and mission work opportunities for me, I hereby freely and voluntarily, on behalf of myself and my successors and assigns, RELEASE and HOLD HARMLESS Hinton Rural Life Center, Inc., its officers, directors, employees, and agents from any and all liability, legal claims of any nature: which may arise during or after the mission trip
and/or which are in any way associated with, arising from, or connected with the mission trip; including but not limited to bodily injury, medical expenses, and death.