Senior High Mission Trip 2015 Participant Information Common Questions: When are we leaving & where are we leaving from? • We will be leaving THE WESTPARK GYM at 1:00PM on SUNDAY, JUNE 12th. (Please arrive on time)
Where will we be staying? • Blueprint Ministries, San Antonio, TX – www.blueprintministry.com When will we back? • THE WESTPARK GYM 9:00PM on FRIDAY, JULY 17th What about emergencies? If you need to reach us you can at the following cell phone #’s: (If we do not answer, please leave a message and we will return your call immediately)
• • •
Chris Sedgwick - 281.851.1786 Ashley Newton - 832.341.4274 Rusty Pregeant (NORTH) – 281.755.5929
What will I need? • A 2016 Medical Release Form if your student has not attended a previous trip in 2016 • A Blueprint Ministry Liability/Participant Health Form/Power Tool Permission
• ALL 4 FORMS MUST BE TURNED IN BY JUNE 6th -
• •
You can turn in these forms on Sunday Mornings, Wednesday Night SG and Monday-Friday at the Church offices between 8:00 AM and 5:00 PM.
Refer to “What to Bring” List (on next page in this packet) for further information Your Final Camp Payment is due 10 days before departure (Call the church office at 832.222.9282 and ask for Ashley Newton or email her at:
[email protected] to get your balance)
What do I need to leave at home? • Clothing with inappropriate messages • Video iPods/Players containing R-rated films, inappropriate pictures, or music containing any explicit lyrics. • You may bring your cell phones, but they must remain in the off position except during approved times. Approved times will be during free time which will be at early afternoons & evenings. What about cell phones, iPads, iPods, etc.? • You student may bring their cell phones, but they must remain in the off position except during approved times. Approved times will be during free time which will be at early afternoons & evenings.
•
If you would like to get in touch with your student and they are not answering their phone, please contact one of our Parkway Student Staff Members. • We recommend your student leave iPads, iPods, Kindles, etc. at home.
What about medication? • If your student takes prescription medication and will be bringing it with them on this trip, IT HAS TO BE IN THE ORIGINAL PRESCRIPTION BOTTLE FOR DISTRIBUTION. IF YOUR STUDENT’S MEDICATION IS NOT IN THE ORIGINAL PRESCRIPTIOIN BOTTLE, THEIR MEDICATION WILL NOT BE DISTRIBUTED TO THEM. FAQ about Medication: • Who will be distributing medication to my student? There will be a nurse that will distribute ALL medication. • Does my student need to bring Advil, Tylenol, Pepto-Bismol, etc. with them? No, the camp nurse will have all these medications and more in her office. Students carrying over the counter medications are prohibited on our trips. • Can I put my student’s prescription medication in a weekly pill dispenser? No, it must be in the original prescription bottle. • Can I put all of my student’s prescription medication in one prescription bottle? No, each separate medication must be in their own original prescription bottle. • My student forgets to take his/ her medication. Will someone remind them? Yes, the nurse knows when all medication is to be distributed and will be in contact with us if your student is not present to receive their medication. • Will my student be able to carry their EpiPen and inhaler with them? Of course! We allow students to carry emergency medication such as EpiPens and inhalers with them. Let us know if your student has emergency medication other than EpiPens and/or inhaler
SENIOR HIGH MISSION TRIP SCHEDULE Sunday, June12th 2:00pm – Depart Parkway Fellowship 5:00pm – Arrive at Blueprint Ministries 5:15pm – Orientation 5:30pm – Leader Meeting 6:30pm – Dinner 7:30pm – Chapel 8:30pm – Team Meeting 10:30pm – Lights out Monday/Tuesday/Wednesday/Thursday 7:00am – Wake Up 7:30am – Breakfast 7:55am – Quiet Time 8:05am – Chores 8:15am – Leader Meeting 8:45am-‐Depart Blueprint 12:00pm - 1:00pm – Lunch 4:30pm – Free time/Shower time 6:30pm – Dinner 7:30pm – Chapel 10:30pm – Lights Out Friday, June 17th 8:00am - Breakfast 9:00am – Chores/Pack 10:00am – Depart BPM for fun day 9:00pm – Arrive at Parkway Fellowship
What To Bring Camper List: Each camper should bring the following item
Need 1. Clothing-‐ Workday-‐ closed toed shoes, t-‐shirts (no tanks or cut offs), pants or shorts of appropriate length, clothes that you can get dirty. Pro tips-‐ Scrubs are a good work day option for pants; Lightweight long-‐sleeved cotton shirts are good for sun and fiberglass protection on worksites Free Time-‐ Comfortable, casual clothes that fit our dress code(i.e. footwear, no short shorts, etc.) 2. Sleeping-‐ Each camper must bring bedding and a pillow. Blueprint provides a mattress and bed, but no linens. 3. Personal Items-‐ Toiletries, towels, washcloths, shower shoes, medications and other personal things 4. Miscellaneous Items-‐ Reusable water bottles for worksite and building, sunglasses, sunscreen, bandanna, hat. **These items are vital to the safety of campers while working at Blueprint
5. Personal Work Gear: None 6. Most Important-‐ A Bible, pen and journal
✔
2016 Parkway Fellowship Student Ministries Medical Release Form I (we) hereby give permission for my (our) child to attend and participate in activities sponsored by Parkway Fellowship and Student Ministries. I (we) hereby authorize Parkway Fellowship to transport my (our) child to or from the sponsored activities and events. I (we) hereby DO consent _____ or DO NOT consent_____ Parkway Fellowship to use pictures taken during this event for promotion of the Student Ministry. I (we) hereby authorize Parkway Fellowship and its acting leaders to teach and lead my (our) child in religious lessons and services which may include prayer and Bible teaching. I (we) hereby authorize any adult, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis treatment, and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the medical practice act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at the said hospital. I (we) hereby DO consent _____ or DO NOT consent_____to the use of blood and or blood products under the care of a licensed physician in the case of an emergency. I (we) hereby do authorize any leader of Parkway Fellowship to dispense to my child any necessary over-the-counter medications (according to proper dosage instructions) when deemed necessary. I (we) hereby authorize any licensed physician or medical treatment center to treat my (our) child in case of an emergency in which the before named physician cannot respond. The undersigned adult shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for my (our) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. I (we) hereby release, forever discharge and agree to hold harmless Parkway Fellowship and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned adult the child-participant that occur while said child is participating in any trip or activity with Parkway Fellowship. Furthermore, I (we) [and on behalf of my (our) child-participant if under the age of 18 years] hereby assume all risk of personal injury, sickness, death, damage and expenses as a result of participation in recreation and work activities involved therein. Further authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agrees to hold harmless and indemnify said church, its directors, employees, volunteers and agents for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. The medical consent and liability waiver provisions hereof shall remain in full force throughout 2016 and in effect until written notice of revocation or withdrawal is received by Parkway Fellowship at its office at 27043 FM 1093, Richmond, Texas 77406 is the responsibility of the parent or guardian to notify the church of any changes in medical condition, guardianship, address or phone change in writing to the address listed at the beginning of this form.
________________________/_________ Father Date
________________________/_________ Mother Date
________________________/_________ ________________________/_________ Legal Guardian Date PARTICIPANT/STUDENT Date ********************************************************************* (Please Complete Both Sides)
Medical Form Student Name _____________________Age____Birth Date________Grade_____ Address___________________________________________Phone______________ City____________________State____Zip________Sex (circle): Male Female Male School Attending________________________________City_________________ Father_______________________________________ Cell Phone______________ Mother_______________________________________ Cell Phone______________ Guardian_____________________________________ Main Phone______________ In Case of Emergency and Parent or Guardian cannot be reached, pleasecontact:
Name___________________Phone___________Relationship_________ Family Physician___________________________Office Phone______________ Family Dentist_____________________________Office Phone______________ Hospital Insurance No. Policy Number______________________ Primary Insured_____________________________ Name of Insurance Company____________________________________________ Insurance Company Phone Numbers______________________________________ List date of last immunization: DPT_______________ MMR_______________ List date of last immunization: Tetanus Only__________ Polio_________ Check if student has had: Chicken Pox______ Measles______ Mumps______ Whooping Cough____ Other__________________________________ Allergies: Foods_____________________________________________________ Medications_______________________________________________ Insects/Bites_____________________________________________ Previous Serious Illness _____________________________Date___________ Current Medication(s)________________________________________________ Special Diet_________________________________________________________ Other Important Medical Information__________________________________ Covenant of Conduct In all meeting, retreats, or other events ender the sponsorship and/or guidance of Parkway Fellowship, I am representing the Christian community and I am responsible for my actions. I understand the following guidelines will be followed: 1. The use or possession of illegal drugs, alcoholic beverages and tobacco are prohibited. 2. All conduct shall be in keeping with the highest Christian regard and respect for all persons. 3. All clothing shall be in good taste and in accordance with the dress requested for the Church event. 4. All individuals are expected to join in group activities. 5. No profanity or sexually inappropriate behavior. I understand the above Covenant of Conduct, and I agree to abide by it to the best of my ability. Youth Signature: __________________________________________ Date: ________________
Blueprint Ministries Participant Health Form Participant Name: ___________________________________________________________________ Birth: ________________________ School: ____________________________________________________________________________ Grade: ___________________________ Address: _____________________________________ City: _______________________________ ST: _______ Zip: __________________ Home Phone: _______________________________ Cell Phone: _______________________ Email: ____________________________ Parent: ______________________________________ Day Phone: _______________________ Cell: ______________________________ Parent: ______________________________________ Day Phone: _______________________ Cell: ______________________________ If my parent is not available in an emergency, please notify: Name: _________________________________________ Contact: _____________________________________________________________ Name: _________________________________________ Contact: _____________________________________________________________ Health History: Please check applicable items: _______Mono _______Bleeding _______Heart Problems _______Mumps _______Cancer _______High Blood Pressure _______Recurring Strep _______Chick Pox _______Hypoglycemia _______Ear Infections _______Diabetes _______Kidney Problems _______Measles _______Knee Problems _______Eating Disorders _______Asthma Allergies: Please check applicable items: _______Hay Fever _______Insect Stings _______Poison Ivy or Oak _______Other: ____________________
Drug Allergies:(List any medication you’re allergic to) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
Other Health Information: Date of Last Tetanus Shot: _________________ (Obtain Tetanus if you are not current) Have you been (in past 12 months) or are you currently being treat for a psychiatric/psychological disorder? ______ If yes, please explain: _________________________________________________________________________ List any previous surgeries or injuries with dates: __________________________________________________________ ____________________________________________________________________________________________________________________ Any illness occurring within the last 5 years that caused you to miss school or work for more than 3 days? _____________________________________________________________________________________________________________ Insurance: I am covered under my parents’ medical insurance plan: ____Yes _____ No Name of insurance company: ____________________________________________________________________________________ I have medical insurance of my own: ____Yes _____No Name of insurance company: ____________________________________________________________________________________ Insurance Policy #: _____________________________________ Policy Phone #: _______________________________________ If you have been out of the country in the past 9 months, where did you go? _______________________________ Consent for Treatment: I hereby give permission to the physician selected by the Blueprint Ministries Director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for myself or child as parent or guardian. Signature: _________________________________________________________ Date: ________________________________________ Printed Name: ____________________________________________________
17 & Younger Liability Release Statement of Activities and Release of Participation Liability Form For Blueprint Ministries Participants Aged Seventeen and Younger, to be Completed by Parent/Guardian Operation Restoration (OR), d.b.a Blueprint Ministries, Incorporated, is an inner city home repair ministry in San Antonio, Texas. Blueprint Ministries is a not for profit corporation. Volunteers participating in Blueprint Ministries will be expected to participate in specific construction activities including, but not limited to, demolition, roofing, carpentry, digging, plumbing, glasswork, painting, flooring, masonry, exposure to hazardous material, and other facets of construction. These activities may include, but are not limited to, the use of power tools such as saws and drills, as well as the use of hand tools. The activities may also require climbing with and without supplies, tools, and materials, as well as working in high places such as roofs, and other facets of construction work. Participants will also be involved in food preparations and service. In their free time, volunteers may choose to engage in activities including, but not limited to, sports, hiking, shopping, touring or other activities of their choosing. Blueprint Ministries may sponsor some recreational activities, which may include but are not limited to swimming, basketball, volleyball, baseball, football, and Frisbee. Other activities include, but are not limited to, travel to homes, parks, theaters, churches, restaurants, and shops. Volunteers are not required to engage in any activity in which they feel they are not able to safely participate. Photo Release: By signing below, I grant Blueprint Ministries, Inc., its representatives, and employees the right to take photographs of me and my property in connection with this ministry. I authorize Blueprint Ministries, Inc., its assigns and transferees to copyright, use, and publish the same in print and/or electronically. I agree that Blueprint Ministries, Inc. may use such photographs of me with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web content. I/We, ___________________________ and __________________________, parent(s) or guardian(s) of ____________________________have read the foregoing statement of activities, understand the extent and nature of the activities in which my/our child/ward will participate, and herby release and discharge Operation Restoration (OR), d.b.a. Blueprint Ministries, Inc., and its officers, directors, agents, employees, volunteers, and all person connected therewith from any and all liability, claims and causes, or action of any type whatsoever arising out of or in any way connected with my/our child’s/ward’s participation in the activities of Operation June 12, 2016 Restoration (OR), d.b.a. Blueprint Ministries, Incorporated, on ______________(start date) through June 18, 2016 _____________(end date). Parent/Guardian Signature: ______________________________________________ Date: ____/____/______ Parent/Guardian Printed Name: __________________________________________ Birth: ____/____/______ Relationship to Child: _______________________ Email: _________________________________________ Phone: _________________________ Address: _________________________________________________ City: _________________________________________________ State: __________ Zip: _______________ Child’s Printed Name: ________________________________________________ Birth: ____/____/______
Parkway Fellowship School Name: ______________________________ Church Name: ___________________________________
18 & Over Liability Release Statement of Activities and Release of Participation Liability Form For Blueprint Ministries Participants Aged Eighteen and Over Operation Restoration (OR), d.b.a Blueprint Ministries, Incorporated, is an inner city home repair ministry in San Antonio, Texas. Blueprint Ministries is a not for profit corporation. Volunteers participating in Blueprint Ministries will be expected to participate in specific construction activities including, but not limited to, demolition, roofing, carpentry, digging, plumbing, glasswork, painting, flooring, masonry, exposure to hazardous material, and other facets of construction. These activities may include, but are not limited to, the use of power tools such as saws and drills, as well as the use of hand tools. The activities may also require climbing with and without supplies, tools, and materials, as well as working in high places such as roofs, and other facets of construction work. Participants will also be involved in food preparations and service. In their free time, volunteers may choose to engage in activities including, but not limited to, sports, hiking, shopping, touring, or other activities of their choosing. Blueprint Ministries may sponsor some recreational activities, which may include, but are not limited to, swimming, basketball, volleyball, baseball, football, and Frisbee. Other activities include, but are not limited to, travel to homes, parks, theaters, churches, restaurants, and shops. Volunteers are not required to engage in any activity in which they feel they are not able to safely participate. Photo Release: By signing below, I grant Blueprint Ministries, Inc., its representatives, and employees the right to take photographs of me and my property in connection with this ministry. I authorize Blueprint Ministries, Inc., its assigns, and transferees to copyrights use and publish the same in print and/or electronically. I agree that Blueprint Ministries, Inc. may use such photographs of me with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising and web content. I, ___________________________, have read the foregoing statement of activities in which I will participate and herby release and discharge Operation Restoration (OR), d.b.a. Blueprint Ministries, Inc., and its officers, directors, agents, employees, volunteers, and all person connected therewith from any and all liability, claims and causes, or action of any type whatsoever arising out of or in any way connected with my participation in the activities of Operation Restoration (OR), d.b.a. Blueprint Ministries, June 18, 2016 June 12, 2016 Incorporated on ______________(start date) through _____________(end date). This is the ________ day of ________________, 20________. 16
Signed: _________________________________________________________ Date: _____/_______/_______ Printed Name: ___________________________________________________ Birth: _____/______/________ Age: ____________ Email: __________________________________________________________________ Phone: ___________________________________________________________________________________ Address: _________________________________________________________________________________ City: _________________________________________________ State: _____________ Zip: _____________
Parkway Fellowship Church/Organization Name: __________________________________________________________________
1. Fill out 2. Print 3. Sign 4. Give original to your leader
>]eS`B]]Z>S`[WaaW]\ 4]`bVSeSSY]TMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM [gQVWZRMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM MMMMMMMMR]Sa<=BVOdS[g^S`[WaaW]\b]caS/
]eS`R`WZZ MMMMMM@SQW^`]QObW\UaOe MMMMMM1W`QcZO`aOe MMMMMMAQ`SeUc\ MMMMMMAOPS`aOe MMMMMM0SZbaO\RS`
>O`S\bAWU\Obc`S(MMMMMMMMMMMMMMMMMMMMMMMMMMMMMM2ObS(MMMMM MMMMM MMMMMMM All forms must be signed by the guardian in ink.
>O`S\b>`W\bSR
>]eS`B]]Z>S`[WaaW]\4]`[
