Minor/Teen Permission Form: June 2023 Trip to Hazard, Kentucky

This form is to be completed by parent or legal guardian if participating minor is under 18 years of age

* = Required field

Minor's Name *

First

Middle

Last

Consent to Participation *

I hereby give permission for this minor to attend and participate in the DREAMBUILDERS MISSION TRIP TO Hazard, KY: Dates: 6/18/23– 6/24/23

Consent to Medical Treatment *

I authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, or hospital care, to be rendered to the minor under the general or specific supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act or the medical staff of a licensed hospital. I will be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the above-named minor pursuant to this authorization.

Behavioral Conduct *

I understand the general guidelines of behavior: that the participant must respect and obey the instructions of the adults(s) in charge, and that any misconduct including sexual misconduct, aggressive behavior, abusive language, tobacco, alcohol, or illegal drugs will not be permitted on this mission trip. Minors may not leave the designated areas within the worksite and volunteer center/camp without an adult over 25 years of age.

Transportation Costs *

I will assume all transportation costs for changes in itinerary should the minor exhibit behavioral problems during this event/activity. I will take full personal and financial responsibility should the minor need to be returned and will hold harmless the adults(s) in charge of DreamBuilders mission events or St Marks, Ascension, Trinity, Christ Church, the Episcopal Diocese of Maryland, or Temple Isaiah for the best effort care of the minor in their charge during the course of the mission trip.

Swimming Participation *

I give permission for my minor to participate in swimming activities while attending the Mission Trip in Hazard, KY

My minor knows how to swim: *

I understand there may be no designated, trained lifeguard and while there will be adult supervision, swimmers swim at their own risk. I will take no civil or legal action against the adult(s) in charge of the swimming activity for the normal care of the minor in their charge.

My minor may receive these over-the-counter medicines dispensed by the adult designated to handle medications on this trip:

NOTE: Consent includes administration of generic equivalents of listed medications.

Media *

I give permission for my minor to be photographed, videotaped, or filmed while participating in the Mission Trip. These photographs/videos may be used for any documentary, inspirational, commemorative or promotional purposes in the spirit of our mission or in support of our church outreach efforts. In addition, these photographs may be used by the DreamBuilders congregations (Ascension, Christ Church, St. Mark’s, Temple Isaiah, or Trinity) for future instructional, inspirational or promotional purposes. The congregations may also use the photographs/videos during meetings/events, in social media, or for display on web sites.

Signature: Parent or legal guardian must sign for missioner under 18 years of age *

Parent or Legal Guardian Name *

First

Last

Email