3 Medical_Liability form - Knoxville Leadership Foundation

Operation Backyard Participant Information/Medical Release
Participant Name:________________________________________________________________Date of Birth: ________________
Address: ________________________________________________________ City/State/Zip: _____________________________
Home Phone: _______________________ Cell Phone: _______________________ Email: _______________________________
Organization: __________________________________________________________ Phone: _______________________________
This Medical treatment Authorization authorizes your Church’s representatives to consent to medical treatment for any accident or illness
occurring while you or your child is participating in the programs of Operation Backyard, Neighborhood Housing, Inc., and Knoxville
Leadership Foundation (collectively “OB”). OB shall not be responsible for authorizing medical care.
Contact Information if Minor Participant
Parent/Legal Guardian(s): (List the names of both custodial parents; if only one custodial parent or for guardianships, enclose a
copy of the most recent court order granting custody.)
Name: ___________________________________________
Name: __________________________________________
Address: __________________________________________
Address: _________________________________________
Cell Phone: ________________________________________
Cell Phone: _______________________________________
Home Phone: ______________________________________
Work Phone: ______________________________________
Emergency Contact: _________________________ Telephone: ________________ Relationship to Student: ______________
Authorization
I/We, _____________________ and _____________________, (names of all parents with custody of student or all guardians),
hereby represent and warrant that we are the sole parents or legal guardians of _____________________ (Student’s Name),
that we have the authority to enter into this authorization for medical treatment of _______________________ (Student’s
Name). I/we hereby authorize ________________________ (Church/Organization) to seek and obtain medical or dental
treatment of the above named student upon any circumstances in which they believe it is reasonably prudent or necessary.
I/we hereby authorize any medical or dental services provider to provide consultation, treatment and services to the above
named student. In the event further or consent for consultation, treatment or services is required, I/we hereby appoint any
employee of _____________________ (Church/Organization) as our/my agent and attorney in fact for the purposes of
authorizing any consultation, treatment and services.
I/we hereby provide the following health information, which I/we believe is all the relevant information a medical provider
should have with regard to the student’s condition in rendering treatment:
Date of last Tetanus shot: ___________________________________________________________________________________
Known Allergies: ___________________________________________________________________________________________
Medications Currently Taking: ________________________________________________________________________________
Any medical or health conditions: _____________________________________________________________________________
Any prior significant medical history: __________________________________________________________________________
In the event any consultation treatment or services are rendered to the above named student while participating in any OB
program, I /we understand and agree the church may not have an opportunity to contact me prior to obtaining medical
consultation, treatment and services. I/we hereby supply the following health insurance information in order for any medical to
obtain reimbursement for their services. I/we hereby agree to pay the provider for any services rendered to the above named
student for which the foregoing insurance does not pay.
Medical Insurance Company: ________________________________________________________________________________
Policy Number: ____________________________________ Group Number: _______________________________________
Subscriber Name and ID No: _______________________________________________________________________________
Authorization of Insurance Company: _________________________________________________________________________
This the_____________ day of ________________, 200_____.
Signed: __________________________________________
State of _______, County of ________ personally appeared before me, a Notary Public, __________, the
within named bargainer, with whom I am personally acquainted (or proved to me on the basis of
satisfactory evidence), and who acknowledged that such person executed the within instrument for the
purposes therein contained. Witness my hand at office on this the _____ day of
_______________________, 20____.
Signed: _________________________________________ Print Name: ___________________________________
*Having this Authorization notarized may facilitate the timely provision of medical services to your child.
Statement of Activities and Release of Liability Form
Operation Backyard (OB) is a home repair ministry of Knoxville Leadership Foundation and Neighborhood
Housing, Inc. Volunteers participating in OB will be engaged in construction activities which may include,
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 types of construction work. Participants may also be involved in food
preparation and service.
In their free time, camp participants (if applicable) may choose to engage in activities including, but not
limited to: Sports, hiking, shopping, touring, or other activities of their choosing. OB 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.
I (Adult age 21 and up) __________________________ or I/we ________________________________ and
_______________________________, (parent(s) or guardian(s) with custody of student), hereby represent
and warrant that we are the sole parents or legal guardians of ____________________________ (student’s
name), and that we have the authority to enter into this release. I/we have read the foregoing statement
of activities, and understand the extent and nature of the activities in which I/my student will participate.
On behalf of my/ourselves, and on behalf of the above named student, I/we hereby fully and finally
release Neighborhood Housing, Inc., Knoxville Leadership Foundation, their respective directors, officers,
employees, volunteers, agents, successors, and assigns (collectively referred to herein as “NHI”), from any
and all claims, causes of action, assertions, and demands arising out of, related to, or otherwise
connected with, howsoever remote, the participation of the above named student in the volunteer
programs of NHI. I/we agree to indemnify and hold NHI harmless from any loss or damages incurred or
resulting from any claim made against NHI on behalf of the above named student or on account of the
above named student.
Adult or Parent/Guardian: _____________________________________ Date: ____________________
Parent/Guardian: ____________________________________________ Date: ____________________
I, ________________________, (student), hereby join in and agree to the release set forth hereinabove. I
also promise and agree with NHI that I will, at all times, follow the supervisors’ directions and instructions
with regard to the performance of volunteer services and safety.
Signed (student): ____________________________________________ Date: ____________________