2024 High School Mission Trip

Student or Adult Leader*
What type of Adult Leader?

Participant's Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
T-Shirt Size*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Email
example@example.com
Participant Email
example@example.com
Participant Cell*

Area CodePhone Number
Grade (Fall of 2024) *
Current School (Fall of 2024)*
Are you a member of White's Chapel?*
If not, where are you a member?
If not, would you like more information about becoming a member at White's Chapel?

YesNo
Parent/Guardian Info
Parent/Guardian #1 Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Parent/Guardian Relationship*
Parent/Guardian #2 Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com

Participant Requests
Roommate/Work Group Request*
List 2 to 3 people
Student Interest and Hobbies
List 2 to 3 options
Any information that WC Students need to know about your student before placing them in a workgroup?

Medical Information and Consent Form

Participant's Medical Information
Does the participant have any allergies?*
List participants allergies (food, medications, etc.)*
Does the participant have any dietary restrictions?*
List participants dietary restrictions*
Gluten, dairy, etc.
Is the participant currently taking prescription medication?*
If yes, please list medication name, dosage, and frequency.*
Does the participant have any medical conditions WC Students should know about?*
If yes, please describe the conditions. *
Date of participant's last tetanus (TDAP) shot:*

MonthDayYear
Date

Insurance Information
Name of Physician*

First NameLast Name
Physician's Phone Number*

Area CodePhone Number
Insurance Company*
Group #*
Policy #
Insurance Phone #

Area CodePhone Number

Emergency Contact Information
Emergency Contact 's Name*

First NameLast Name
Emergency Contact 's Phone Number*

Area CodePhone Number

Medical Release
I, hereby affirm that (I, or my child) shall be participating in activities sponsored by White’s Chapel Methodist Church, hereinafter referred to as “the activities”. I certify that I am cognizant of the inherent dangers associated with participating in the Activities and with the fact that participating in the Activities may take place outside of, or off, premises. I understand and agree that neither White’s Chapel, nor its trustees, nor representatives, nor instructors, nor agents may be held liable in any way for any occurrence in connection with my or my child’s participation in the activities that may result in injury, harm, or other damages to my family or me. As a part of the consideration for being allowed to enroll and participate in the Activities, I hereby personally assume all risks in connection with participation in the Activities. I further release White’s Chapel, its trustees, instructors, agents, and representatives for any injury or damage which may befall while enrolled or participating in the Activities. I further agree to save and hold harmless White’s Chapel, its trustees, agents, and representatives from any claim by me, or my family, estate, heirs, or assigns arising out of enrollment and participation in the Activities. I further state that I am of lawful age and legally competent to sign the affirmation and release: that I understand the terms herein and contractual and not a mere recital: and that I have signed this document of my own free act and coalition. I further state and acknowledge that I have fully informed myself of the contents of this affirmation and release by reading it before I have signed it.
Digital Signature*
Typing your name acts as your signature for the above release.
Date*

MonthDayYear
Today's Date

Consent for Treatment
I, hereby affirm that (I, or my child) do hereby appoint the adult in charge of this event as his/her agent as my true and lawful, attorney in fact to act for me and in my name, place and stead; and to do any, every and all acts and exercise any, every and all powers that I might or could do in giving consent to emergency or non-emergency medical treatment for my minor child that he/she shall deem proper or advisable to do or exercise on my behalf. This appointment of the authorized adult sponsor as my attorney-in-fact for the limited purpose of consenting to emergency or non-emergency medical treatment for the above named minor child shall not terminate on my physical or mental disability subsequent to the date of execution hereof.
Digital Signature*
Typing your name acts as your signature for the above release.
Date*

MonthDayYear
Today's Date

Over the Counter Medication Authorization Release Form
White’s Chapel Student Mission Trip Events

The White’s Chapel medical volunteers will provide basic first aid supplies to students (bandages, cold packs, etc.) as well as over-the-counter medications if deemed necessary by the medical volunteer.

All medications brought on Student Events must be checked in with the Team Leader and listed on the above Release Form. It is recommended that only necessary prescription medications be brought on the trip as the medical volunteers will have over-the-counter medications available if needed. If you have questions concerning this matter, please discuss with a medical volunteer.

Sign below if you agree for the medical volunteer to dispense any needed over-the-counter medication per package directions. Examples of these medicines include:

Acetaminophen (Tylenol) or generic pain reliever/fever reducer
Ibuprofen (Advil) or generic pain reliever/fever reducer
Midol or generic menstrual cramp meds
Benadryl or generic hay fever or upper respiratory allergies
Nasal and sinus congestion meds
Cough drops or throat lozenges for cough/throat irritation
Dramamine or nausea medicine for motion sickness

If we do not have a parent or guardian’s signature, we will contact you prior to dispensing over-the-counter medications to your child.

I give permission for the medical volunteer to dispense over-the-counter medication(s) to my child for self-administration at the medical volunteer’s discretion or dispensed by designated personnel as delegated by the medical volunteer. Additional comments may be written below signature.
I DO give my consentI DO NOT give my consent
Digital Signature*
Typing your name acts as your signature for the above release.
Date*

MonthDayYear
Today's Date

Code of Conduct
Code of Conduct

ALL PARTICIPANTS (STUDENTS AND ADULTS) AGREE TO THE FOLLOWING BY READING AND CHECKING THE BOX BELOW.
I will not participate in or have possession of illegal drugs, alcohol, firearms, or fireworks. I will abide by the laws of the state I am serving in. I know that illegal activity will be reported immediately to local authorities.

I will operate safely by not leaving the lodging campus without an adult 21 years or older. I will not change room assignments so my location is known in case of an emergency. I will respect the scheduled “lights out” time.

I will respect the privacy of others by not entering into areas designated for the opposite sex. I will honor people, places, and authorities by not using obscene language, acting in reckless behavior harmful to others or myself, respecting the local community by not damaging the facilities or properties.

I will respect others by not using tobacco at the work site, at the lodging facility, in the neighborhoods I serve in, and I understand that it is illegal to use tobacco on event grounds.

I will recognize and submit to the authority of the WC Students staff.

I will not engage in inappropriate sexual activity including obscene gestures, comments, or physical contact. I also know that such behavior will be reported to local authorities if warranted by law.

I know that I am a willing participant in a missions trip activity. I know that I may not have the conveniences of home. I will not bring valuables that cannot be stored with me at all times.

Out of respect for others, I will dress modestly. I will not behave in a way that causes distractions or disruptions to other participants.

In order to build relationships with my leaders and other students, I will not text message or use my cell phone, iPod, etc. on worksites, activities or during worship programs.

ADULT SPECIFIC (21 AND OLDER)

I will serve as a positive role model for students and others. I will participate with a positive attitude and team effort during the event.

I will show respect to the WC Students staff, local authorities, leaders, and youth participants.

I will avoid and refuse to participate in any inappropriate sexual activity including comments, gestures, or physical contact.

I/We will respect God, the local community, and our youth group by abiding to this Code of Conduct. Violation of the Code of Conduct may forfeit the privilege of participating in this missions trip and I may be asked to leave (without reimbursement and at my own expense) at the request of the WC Students staff, or my group leader.
I Agree
Digital Signature*
Typing your name acts as your signature for the above release.
Date*

MonthDayYear
Today's Date

Almost done! Kindly review all info if correct.*

I have reviewed that all information is true and correct.
Should be Empty:

Participant's Information

Parent/Guardian Info

Participant Requests

Medical Information and Consent Form

Code of Conduct

Work Group Leader Experience