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2017 Project Timothy Midwest South

PERMISSION/MEDICAL RELEASE FORM

PERMISSION AND RELEASE

As the parent (or guardian) of the above named attendee, I grant permission for my son or daughter to attend Project Timothy 2017 and authorize Project Timothy youth leaders and chaperons, to transport and supervise my student in connection with his or her attendance at Project Timothy. I do further hereby give, release, absolve, indemnify, and agree to hold harmless, Vineyard Community Church (host church), staff, volunteers, and persons transporting my son/daughter to and from the activity and associated activities from any claim arising out of injury to my son or daughter.


Date: June 9, 2023

MEDICAL CARE AUTHORIZATION

As the parent (or guardian) of the above named attendee, I hereby authorize Project Timothy and its chaperones to seek and have emergency medical first aid administered to the above named attendee during the 2017 year.


Date: June 9, 2023

WAIVER OF PUBLICITY FORM

I give permission for the use of any photos, movies, and audio or video tapings of my student's activities in connection with Project Timothy, to be used with Vineyard USA's approval for religious purposes, media coverage, or for publicity benefiting religious purposes.


Date: June 9, 2023

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Health Insurance Provider *

Policy # *
Are there any special health conditions of which Project Timothy Staff should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*
No
Yes

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
No
Yes
If yes:*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Health Insurance Provider *

Policy # *
Are there any special health conditions of which Project Timothy Staff should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*
No
Yes

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
No
Yes
If yes:*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Health Insurance Provider *

Policy # *
Are there any special health conditions of which Project Timothy Staff should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*
No
Yes

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
No
Yes
If yes:*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Health Insurance Provider *

Policy # *
Are there any special health conditions of which Project Timothy Staff should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*
No
Yes

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
No
Yes
If yes:*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Health Insurance Provider *

Policy # *
Are there any special health conditions of which Project Timothy Staff should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*
No
Yes

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
No
Yes
If yes:*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Health Insurance Provider *

Policy # *
Are there any special health conditions of which Project Timothy Staff should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*
No
Yes

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
No
Yes
If yes:*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Health Insurance Provider *

Policy # *
Are there any special health conditions of which Project Timothy Staff should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*
No
Yes

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
No
Yes
If yes:*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Health Insurance Provider *

Policy # *
Are there any special health conditions of which Project Timothy Staff should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*
No
Yes

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
No
Yes
If yes:*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Health Insurance Provider *

Policy # *
Are there any special health conditions of which Project Timothy Staff should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*
No
Yes

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
No
Yes
If yes:*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Health Insurance Provider *

Policy # *
Are there any special health conditions of which Project Timothy Staff should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*
No
Yes

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
No
Yes
If yes:*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent/Guardian Info

Names of Parents/Guardians

Home Phone *

Work Phone

Cell Phone

Persons to call if Parent or Guardian cannot be reached in case of emergency:


Name *

Phone *

Name

Phone
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Health Insurance Provider *

Policy # *
Are there any special health conditions of which Project Timothy Staff should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*
No
Yes

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
No
Yes
If yes:*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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