• Medical and Media Release Form

    • This release will cover you/your child for all St. Martin's Episcopal Church (SMEC) activites from July 1, 2019 - August 31, 2020.
    • Every person participating in SMEC activities MUST have a signed release on file with SMEC.
    • This document must be filled out by the adult participant, or the minor participant's custodial parent or legal guardian.

  • Participant Information

  • Date of Birth*
     - -
  • Gender*
  •  -
  •  -
  •  -

  • Emergency Contact(s)

    For minors, if parent/guardian is unavailable in an emergency, notify:
  •  -
  •  -

  • Medical Information

  •  -
  •  -
  • Policy Holder Date of Birth*
     - -

  • Please attach a copy of the front and back of the policyholder's insurance card.

  • Minor Medical Release

  • I hereby give my permission for my child

  • to attend St. Martin's Episcopal Church (SMEC) events. I (we) understand that in the event medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, I give my permission to SMEC leadership to secure any and all emergency medical care including anesthesia for my child in the event I cannot be reached by telephone. I further agree to accept full responsibility for any accident or illness incurred by my child at an SMEC event, and I will not hold responsible SMEC, its staff, trip leaders, its officers, or any of the sponsors of an SMEC event for the accident or illness. In the event that I cannot be reached by telephone, I authorize SMEC staff, trip leads, officers, and sponsors of an SMEC event to contact St. Martin's Student Ministries (SMSM) staff persons who I have fully authorized and empowered to make any and all necessary decisions for my child's well-being. I agree to reimburse SMEC, its staff, trip leaders, officers, and sponsors of an SMEC event for the cost of any and all medical treatment paid for on behalf of my child. I also understand that if my child is caught with alcohol, drugs, or any weapons of any kind, he/she will be sent him immediately at my additional expense.

  • Adult Medical Release

  • agree to attend St. Martin's Episcopal Church (SMEC) events. I understand that in the event that medical treatment is required, I give my permission to SMEC leadership to secure any and all emergency medical care including anesthesia for myself. I further agree to accept full responsibility for any accident or illness incurred by myself at an SMEC event, and I will not hold responsible SMEC, its staff, trip leads, its officers, or sponsors of a SMEC event to contact other SMEC staff persons who I have fully authorized and empowered to make any and all necessary decisions for my well-being. I agree to reimburse SMEC, its staff, trip leads, officers, and sponsors of any event for the cost of any and all medical treatment paid for on behalf of myself. I also understand that if I am caught with alcohol, drugs, or any weapons of any kind, I will be sent home immediately.

  • HIPAA Release Authority

  • intend for SMEC to be treated as I would be treated with respect to my rights regarding the use and disclosure of my individually identifiable health information and other records.   This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 42 USC 1320d and 45 CFR 160-164.  This release authority is effective immediately.  Accordingly, I hereby authorize any doctor, physician, medical specialist, psychiatrist, chiropractor, health-care professional, dentist, optometrist, health plan, hospital, clinic, laboratory, pharmacy or pharmacy benefit manager, medical facility, pathologist, or other provider of medical or mental health care, as well as any insurance company (referred to herein as a "covered entitiy"), to give, disclose and release to SMEC who is named herein, without restriction, all of my individually identifiable health information and medical records regarding any past, present or future medical condition.  Additionally, SMEC shall have the ability to ask questions and discuss my protected medical information with the person or entity who has possession of the protected medical information even if I am fully competent to ask questions and discuss this matter at the time.  It is my intention to give full authorization to any protected medical information to SMEC.  Further, in order to fulfill my intent as expressed herein, I authorize SMEC to sign any documentation that SMEC deems necessary or appropriate in order to secure the disclosure of my individually identifiable health information and other medical records.   Any information disclosed to SMEC may subsequently be disclosed to another party by SMEC.  The authority given to SMEC shall expire on August 31, 2020.

  • Indemnify and General Release

  • WHEREAS, I the undersigned, have registered myself/my child to participate in a St. Martin's Episcopal Church (SMEC) program, and other related activities from date signed through August 31, 2020 at St. Martin's Episcopal Church, 717 Sage Road, Houston, Texas 77056; WHEREAS, I have agreed to provide this release and indemnity.  NOW THEREFORE, PREMISES CONSIDERED, which premises form a part of this agreement, I,

  • do hereby release, indemnify and hold harmless St. Martin's Episcopal Church, and each of its officers, vestry members, agents, employees, and clergy (collectively the "Church") from and against any claim, liability (including negligence) or cause of action, INCLUDING ANY CLAIM, LIABILITY OR CAUSE OF ACTION RELATING TO THE NEGLIGENCE OF THE CHURCH, relating directly or indirectly to any claim, cause of action or liability I, any child of mine, or heirs of mine may have or assert against the Church relating to participation in any program or other activity, conducted in or relating to, a SMEC program.

  • Media Release

  • I hereby give my full consent to St. Martin's Episcopal Church (SMEC) to record myself/my child(ren)'s participation in any programs or events associated with SMEC environment.  Further, I hereby transfer and assign to SMEC the exclusive rights to use and authorize others to use said images, video, and audio recordings for promotional and educational use or resource sale in the future.  I understand that my/their image may be used, but my/their name or personal information will never be shared publicly without additional, separate consent.

  • By signing below I certify that I have read and agree to all waivers above:

  • Clear
  • Date*
     - -
  • Relationship to Participant*
  • Participant's Date of Birth*
     - -

  • IMPORTANT: 

    BEFORE HITTING SUBMIT, please make sure you have printed the document above.  It is a required document and must be signed and notarized before returning it to Student Ministries.  Once you hit submit, you cannot go back and print.  To print, click on the document and select the printer icon.  Thank you!

  • St. Martin's Mission Trip Participant Manual

    2 Corinthians 5:20 We are therefore Christ's ambassadors

  • Mission trip members are ambassadors of Jesus Christ, St. Martin's Episcopal Church (SMEC) and the United States. Before accepting this responsibility, we ask that you prayerfully consider your attendance and read this document in order to understand the church's expectations while on the trip. These guidelines are meant to create fellowship, a servant heart, and safety. We ask that all mission trip participants read and sign this manual demonstrating that you understand all that is asked and expected of you/your family. Please make a copy for yourself before and during the mission trip.

  • Participant Behavior:  Ephesians 2:10 For we are God's handiwork, created in Christ Jesus to do good works, which God preapred in advance for us to do.

    • Mission trip partcipants will keep God and the goals of the mission trip at the heart of their emotions, thoughts, and actions.
    • Mission trip participants will keep a positive attude, regardless of circumstance.
    • Mission trip participants will complete and abide by the Safeguarding God's Children Training.
    • Every mission trip site has different lodging accomodations (open rooms, shared rooms, personal beds, tents, etc.) therefore the mission Trip Lead(s) will decide lodging for all mission trip participants.  Mission trip participants will be flexible about room changes.
    • Many cultures are put off or offended by public displays of affection such as hand holding, hugs, and kissing.  Mission trip participants will be sensitive to this on the mission field.  Additionally, mission trip participants who are dating or married to another trip participant are asked to respect the culture and refrain from physical affection in public during the duration of the trip.
    • Mission trip particpants will not enter into a closed door setting with a non-family member or a mission trip client.  Groups of three are always encourage to promote safety.
    • Mission trip participants will approach the Trip Lead(s) immediately if they ever feel like their physical boundaries are violated. 
    • Mission trip participants are responsible for their behavior.  If you break or damage something, you will be responsible for replacement/compensation.
    • Mission trip participants will make sure that the Trip Lead(s) knows where they are at all times.  The mission tream will stay together and travel as a unit for the trip duration, unless specified by the Trip Lead(s).
    • Mission trip participants will respect and follow the decisions of the Trip Lead(s) as they pertain to the mission trip. (See Policy Enforcement at end of document)

  • Participant Age/Abilities: 1 Thessalonians 1:4 For we know, brothers and sisters loved by God, that He has chosen you...

    • Family and General Mission Trips:  Mission Trip participants in grades 3rd-8th must be accompanied by an adult/guardian.
    • General Mission Trips:  Mission trip participants who are in high school and older may attend trips without a parent/guardian.
    • To promote a safe environment for our Mission trip participants and for the Mission partners that we serve, we require that a background check and sex offender registery check be completed on all participants 18 and over.
    • Mission trip particpants traveling alone and/or who have physical ailments must take into consideration the schedule and physical demands of the mission trip prior to completing an application.
    • SMEC and the mission trip site will strive to make reasonable accomodations for mission trip participants upon request, and as we are able.

  • Alcohol/Drugs: Colossians 3:17 And whatever you do, whether in word or deed, do it all in the name of the Lord Jesus, giving thanks to God the Father through Him.

    • SMEC will not purchase alcohol (this includes SMEC petty cash and credit card).
    • Mission trip participants drinking alcohol must be the age of 21 and over.
    • No drugs illegal to the United States, Texas or the mission trip location are allowed on the trip.
    • Tobacco (including vaping) is allowed for mission participants age 18 and older.  Tobacco is not allowed at the mission trip site, or during times of prayer/church.
    • Mission Trip Lead(s) have the right to create additional trip specific alcohol policies.  All mission trip participants must abide by these trip specific policies.  (See Policy Enforcement at end of document)

  • Language:  Ephesians 4:29 Do not let any unwholesome talk come out of your mouths, but only what is helpful for building others up according to their needs, that it may benefit those who listen.

    • Mission trip participants will not make derogatory comments or get involved in arguments reguarding politics, religion, race, and other controversial topics.  Trip participants will refrain from meddling, complaining, and using obscene or insensitive humor.  (See Policy Enforcement at end of document)

  • Weapons:  Galatians 5:13-15 You, my brothers and sisters, were called to be free.  But do not use your freedom to indulge the flesh; rather, serve one another humbly in love.  For the entire law is fulfilled in keeping this one command:  "Love your neighbor as yourself."  If you bite and devour each other, watch out or you will be destroyed by each other.

    • Mission trip participants will not have in their posession fireworks, firearms, bullets, knives, boomerangs, or other weapons.  Most airlines will not allow sharp objects on airplanes, please keep this in mind while packing.  Our biggest priority for the mission trip is a safe space for all.  (See Policy Enforcement at end of document)

  • Electronic Devices (cell phones, smart watches, iPods/music playing devices, iPads/tablets, laptops, etc.):  Colossians 4:5 Be wise in the way you act toward outsiders; making the most of every opportunity.

    • Mission trip participants may use the functions of their cell phones and smart watches (i.e. time and photo), but may not utilize communication services (social media, calls, texting, facetime, skype, video chatting), as long as it does not take away from the mission work of the trip.  Other types of electronics should be stored in participant backpacks or back at the trip lodging.  Please take into consideration the conservative culture of the organization that you are entering.  If they shy away from electronic devices, then minimize use.
    • Respect the confidentiality of the poeple you are working with on your mission trip by not sharing names, addresses, or other identifying information on social media.
    • When back at the lodging, all electronic device use is allowed.  However, SMEC encourages trip participants to be in community with one another through conversation, prayer, and activiites.
    • SMEC does not assume the liability of trip particpants lost, stolen or damaged electronic devices. (See Policy Enforcement at end of document)

  • Medical:  2 Thessalonians 2:16-17 May our Lord Jesus Christ Himself and God our Father, who loved us and by His grace gave us eternal encouragement and good hope, encourage your hearts and strengthen you in every good deed and word.

    • Mission trip participants will notify their medical professional of participation in the mission trip in order to seek advice on medications/medical needs and immunizations.
    • Mission trip participants will consult the state department (www.state.gov), Center for Disease Control website (http://wwwn.cdc.gov/travel) to see which immunizations are suggested for the mission trip location of travel.
    • Mission trip participants will check the state department (www.state.gov), and the Center for Disease Control website (http://wwwn.cdc.gov/travel) to see if there are requirements for medication (i.e. in original bottles, bring prescriptions, or restrictions on over-the-counter medications.
    • Mission trip participants will immediately report any illness to the Trip Lead(s).

  • Clothing:  Ephesians 5:3-4 But among you there must not be event a hint of sexual immoraltiy, or any kind of impurity, or of greed, becasue these are improper for God's holy people.  Nor should there be obscenity, foolish talk or coarse joking, which are out of place, but rather thanksgiving.

    • Mission trip participants will abide by the trip packing list.
    • Mission trip participants will take into consideration the mission trip location culture.
    • Mission trip participants will take modesty into consideration.
    • Mission trip participants will dress weather appropriate.
    • Mission trip participants will bring enough clothes for the entirelty of the trip. (See Policy Enforcement at end of document)

  • Gifts: Galatians 5:22-23 But the fruit of the Spirit is love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, self-control;

    • Mission trip participants will consult the Trip Lead(s) before purchasing any gifts, food, or treats for the mission trip partners and their clients.
    • Mission trip participants will not expect or accept gifts from the partner organization and its clients.  Gifts may only be accepted if approved by the Trip Lead(s).  (See Policy Enforcement below)

  • Policy Enforcement: Philippians 1:27 Whatever happens, conduct yourselves in a manner worthy of the gospel of Christ.

  • the mission trip participant, have read and understand this mission trip participant manual.  It is out of respect of God, myself, my fellow mission trip particpants and the mission trip clients that we are serving that I abide by these rules.

    • If a policy is not abided by, the Trip Lead(s) have the power to decide the course of action that should be taken, including being sent home at the expense of the participant/guardian.  If a participant is removed from the mission trip, the Trip Lead(s) will be responsible for carrying out the details to make this happen.
    • The Trip Lead(s) have the authority to immediately remove participants who pose a threat to themselves and/or others, participate in illegal activity, and/or create significant discruptions to the other mission trip constituents.
  • Date
     - -
  • Clear
  • Clear
  • Image field 89
  •  
  • Should be Empty: