MK Consent and Release 2015

MISSIONARY KID PROGRAM 2015Application, Consent & ReleasePage 1 of 8

MINOR APPLICATION AND RELEASE (under 18)

For your child to be a participant in the Preachin Time Ministries Missionary KidsProgram for 2015, please complete the following information. If an ID (Drivers Lic,Passport, School ID) is available, please provide a copy. A copy of your insurance cardis required.

NAME: _____________________________________________________________

ADDRESS: __________________________________________________________

CITY: ____________________________ STATE ________ ZIP ______________

PHONE #: ( )__________________ AGE ___ BIRTHDAY _____/____/____

MALE ____ FEMALE ______ GOLF SHIRT SIZE ____ TSHIRT SIZE ____

EMAIL ADDRESS: __________________________________

PARENTS NAME: _____________________________________________________

PARENTS ADDRESS: ___________________________________________________(if different)CITY: ____________________________ STATE ________ ZIP _______________

HOME CHURCH: ______________________________ PASTOR _________________

CHURCH MAILING ADDRESS: _____________________________________________

CITY: ____________________________ STATE ________ ZIP _______________

EMERGENCY CONTACT:

NAME ________________________ RELATIONSHIP _____ PHONE_______________

ALTERNATE #s (cell, work) ________________________________________________

MEDICAL INFORMATION (MUST BE COMPLETED!)Please List All Medical Conditions Host or Medical Personnel Should be aware of: (Include Medical Allergies, MedicationAllergies, Food Allergies, Other Allergies like bee stings, etc; skin diseases, asthma, heart conditions, etc)

Medications: (Please List ALL medications of ANY TYPE prescription, over the counter your child takes and/or has intheir possession. Include INSTRUCTIONS. Also indicate if you want Trip Staff to assist in dispensing the medication on yourbehalf.)


Physical Restrictions: (You Child is expected to FULLY PARTICIPATE in activities unless medically unable to do so.)

Date of Last Tetanus or Booster: ____________________

MINOR CONSENT AND RELEASE FORM: (under 18 years of age)(All Custodial Parents/Guardians Must Review and Sign)

I, the undersigned parent or guardian, hereby consent to my child, ________________________, who is ____ years ofage, participating in the activities connected with Preachin Time Ministries Missionary Kids Program (herein referred to asTHE PROGRAM). THE PROGRAM is an activity sponsored by Preachin Time Ministries and Evangelist Duane Moore (anOutreach Ministry of White Oak Springs Baptist Church). THE PROGRAM will be held during June and July 2015 (but may beextended in the event of travel considerations). Some participants will only be present for a portion of the trip and may travelon alternate dates. The PROGRAM will involve activities at several locations and include transportation to and from thosevarious locations and activities. I certify that my child is able to participate in these activities, including sports, horse backriding, swimming (note: Not all activities may be available at this function) and other trip related activities (unless indicatedin the medical information section of this application). If my child has a medical condition which may be relevant to aphysician in the event of an emergency, I have listed them above in the medical section of this application. In the event of anemergency, I may be reached at the telephone number listed above in this application. If I cannot be reached within areasonable period of time, I hereby authorize Duane Moore, director or his designated adult assistant to make emergencymedical decisions for my child. I authorize Duane Moore or his designated assistant to administer basic first aid and over thecounter medications as needed. If there are any activities that I do not want my child to participate in, I have listed thembelow my signature. Furthermore, I agree to the uncompensated use of any and all pictures, videos and other recordings ofmy child by PTM or any associated ministry in promotional materials, websites or any other use these ministries may choose.

I understand that my child may ride in the vehicle with individuals designated by Preachin Time Ministries or Duane Moore.I specifically consent to my child being transported by this designated driver and extend my release of liability to any of thesedrivers.

I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISK WHICH MAY BE ENCOUNTERED ON SAID ACTIVITIES,INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do herby agree to hold Bro. Duane Moore, White OakSprings Baptist Church, Preachin Time Ministries, Wahoo Baptist Church (DBA Northeast Georgia Youth Camp/Power of TwoYouth Camp), All supporting churches and individuals, associated missionaries and institutions, their churches, supporters,boards and ministries, and their employees, agents, volunteer assistants and associates, harmless from any and all liability,actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resultingin death, which I now have or which may arise in the future in connection with the activity or participation in any otherassociated activities. This release is given with the express intention of binding myself, my spouse, legal representatives,heirs and assigns.

I EXPRESSLY AGREE TO ASSUME ALL FINANCIAL RESPONSIBILITY FOR ANY MEDICAL TREATMENT NECESSARY FOR MY CHILD.

Insurance Company ______________________ Policy/ID _________________ Employer _____________________***PLEASE ATTACH A COPY OF YOUR INSURANCE CARD FRONT AND BACK *** _____ check here if NO insurance

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted bythe law of the State of Georgia and that if any portion thereof is held invalid, it is agreed that the balance shall,notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto,and the terms of this release are contractual and not a mere recital.

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THISRELEASE AS MY OWN FREE ACT. This is a legally binging agreement which I have read and understand.

______________________________ _________ _____________________________ ________Parent or Guardian Date Parent or Guardian Date


__________________________________________ _________________________________________Day time Phone # Cell Phone# Day time Phone # Cell Phone#

I do not wish my child to participate in the following:

________________________________________________________________________________________________

CODE OF CONDUCT

PTM reserves the right to set and enforce their statement of Faith, rules for behavior and otherrequirements as necessary. This includes but is not limited to: King James Only program, AppropriateDress Requirements (no shorts, tanks, etc for Males No pants, Shorts, immodest tops for Females);Full participation in all activities and services; details are determined by the director. Preachin TimeMinistries has a STANDARD CODE OF CONDUCT that will be in effect for the Program. Obtain a copy atwww.preachintime.com or by mail.

I ________________________________ (MK), am familiar with the dress code, doctrine anddiscipline statements for the PTM STANDARD CODE OF CONDUCT. I agree to willing abide by theserules, be a good sportsman, dress according to PTM policy and exhibit a good Christian disposition atall times. I agree to follow the directives of the director and leadership at all times. I desire to cometo the PTM MK PROGRAM and do so at my own risk. I understand that failing to comply with theserules may result in my dismissal and require my parent/guardian to make arrangements for my earlydeparture.

MK Signature ______________________________________Parent: I agree to this statement ____________________________________________________


ADULT APPLICATION AND RELEASE (18 and over)

For you to be a participant in the Preachin Time Ministries Missionary Kids Programfor 2015, please complete the following information. If an ID (Drivers Lic, Passport,School ID) is available, please provide a copy. A copy of your insurance card isrequired.

NAME: _____________________________________________________________

ADDRESS: __________________________________________________________

CITY: ____________________________ STATE ________ ZIP ______________

PHONE #: ( )__________________ AGE ___ BIRTHDAY _____/____/____

MALE ____ FEMALE ______ GOLF SHIRT SIZE ____ TSHIRT SIZE ____

EMAIL ADDRESS: __________________________________

PARENTS NAME: _____________________________________________________

PARENTS ADDRESS: ___________________________________________________(if different)CITY: ____________________________ STATE ________ ZIP _______________

HOME CHURCH: ______________________________ PASTOR _________________

CHURCH MAILING ADDRESS: _____________________________________________

CITY: ____________________________ STATE ________ ZIP _______________

EMERGENCY CONTACT:

NAME ________________________ RELATIONSHIP _____ PHONE_______________

ALTERNATE #s (cell, work) ________________________________________________

MEDICAL INFORMATION (MUST BE COMPLETED!)Please List All Medical Conditions Host or Medical Personnel Should be aware of: (Include Medical Allergies, MedicationAllergies, Food Allergies, Other Allergies like bee stings, etc; skin diseases, asthma, heart conditions, etc)

Medications: (Please List ALL medications of ANY TYPE prescription, over the counter your child takes and/or has intheir possession. Include INSTRUCTIONS. Also indicate if you want Trip Staff to assist in dispensing the medication on yourbehalf.)

Physical Restrictions: (You Child is expected to FULLY PARTICIPATE in activities unless medically unable to do so.)


Date of Last Tetanus or Booster: ____________________

ADULT CONSENT AND RELEASE FORM: ( 18 years of age and older)I, __________________________________ age ______, the undersigned, hereby consent to my participation in theactivities connected with Preachin Time Ministries Missionary Kids Program (herein referred to as THE PROGRAM). THEPROGRAM is an activity sponsored by Preachin Time Ministries and Evangelist Duane Moore (an Outreach Ministry of WhiteOak Springs Baptist Church). THE PROGRAM will be held during June and July 2015 (but may be extended in the event oftravel considerations). Some participants will only be present for a portion of the trip and may travel on alternate dates. ThePROGRAM will involve activities at several locations and include transportation to and from those various locations andactivities. I certify that I am able to participate in these activities, including sports, horse back riding, swimming (note: Notall activities may be available at this function) and other trip related activities (unless indicated in the medical informationsection of this application). If I have a medical condition which may be relevant to a physician in the event of an emergency, Ihave listed them above in the medical section of this application. I hereby authorize Duane Moore, director or his designatedadult assistant to make emergency medical decisions for me. If there are any activities that I cannot participate in, I havelisted them below my signature. Furthermore, I agree to the uncompensated use of any and all pictures, videos and otherrecordings of my child by PTM or any associated ministry in promotional materials, websites or any other use these ministriesmay choose.

I understand that I may ride in the vehicle with individuals designated by Preachin Time Ministries or Duane Moore. Ispecifically consent to being transported by this designated driver and extend my release of liability to any and all of thesedrivers.

I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISK WHICH MAY BE ENCOUNTERED ON SAID ACTIVITIES,INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do herby agree to hold Bro. Duane Moore, White OakSprings Baptist Church, Preachin Time Ministries, Wahoo Baptist Church (DBA Northeast Georgia Youth Camp/Power of TwoYouth Camp), All supporting churches and individuals, associated missionaries and institutions, their churches, supporters,boards and ministries, and their employees, agents, volunteer assistants and associates, harmless from any and all liability,actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resultingin death, which I now have or which may arise in the future in connection with the activity or participation in any otherassociated activities. This release is given with the express intention of binding myself, my spouse, legal representatives,heirs and assigns.

I EXPRESSLY AGREE TO ASSUME ALL FINANCIAL RESPONSIBILITY FOR ANY MEDICAL TREATMENT NECESSARY FOR ME.

Insurance Company ______________________ Policy/ID _________________ Employer _____________________***PLEASE ATTACH A COPY OF YOUR INSURANCE CARD FRONT AND BACK *** _____ check here if NO insurance

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted bythe law of the State of Georgia and that if any portion thereof is held invalid, it is agreed that the balance shall,notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto,and the terms of this release are contractual and not a mere recital.

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THISRELEASE AS MY OWN FREE ACT. This is a legally binging agreement which I have read and understand.

______________________________ _________Signature Date

I do not wish to participate in the following:

________________________________________________________________________________________________


CODE OF CONDUCT

PTM reserves the right to set and enforce their statement of Faith, rules for behavior and otherrequirements as necessary. This includes but is not limited to: King James Only program, AppropriateDress Requirements (no shorts, tanks, etc for Males No pants, Shorts, immodest tops for Females);Full participation in all activities and services; details are determined by the director. Preachin TimeMinistries has a STANDARD CODE OF CONDUCT that will be in effect for the Program. Obtain a copy atwww.preachintime.com or by mail.

I ________________________________ (MK), am familiar with the dress code, doctrine anddiscipline statements for the PTM STANDARD CODE OF CONDUCT. I agree to willing abide by theserules, be a good sportsman, dress according to PTM policy and exhibit a good Christian disposition atall times. I agree to follow the directives of the director and leadership at all times. I desire to cometo the PTM MK PROGRAM and do so at my own risk. I understand that failing to comply with theserules may result in my dismissal and require my parent/guardian to make arrangements for my earlydeparture.

MK Signature ______________________________________


NAME: ______________________________________________

My anticipated arrival date is ___________________ at _________________________I will be arriving with _____________________________________________________My anticipated departure date is _____________________ from ___________________I will be departing with ____________________________________________________

I intend to participate in the activities checked below:

________________________________________ ________________________________________ ________________________________________

(list pre-dates that you intend to participate in above) June 27 Camp Work Day June 28 God and Country Weekend Jun 29-July 1 Junior Camp (camper or worker depending on age)* July 1-3 MK SPECIAL ACTIVITES (Pigeon Forge) July 4-5 Prep Weekend July 6-10 Teen Camp ________________________________________ ________________________________________

(list post-dates that you intend to participate in above)

DO YOU HAVE A 2015 DOLLYWOOD SEASON PASS? YES NO

*There is a special form for those volunteering at Junior camp.IF you are 18 or over and want to volunteer at JUNIOR CAMP, youwill be ask to submit to a back ground check. Please [email protected] for a form.


CODE OF CONDUCTBro. Mark Stroud, Bro. Duane Moore and the camp staff reserve the right to set and maintain the highest Biblical Standards in keeping with Consistent ChristianConduct. Please review this summary of our standards. Please note that this list is intended to be general, and the directors have final authority to apply andinterpret these standards.

Doctrine: The Northeast Georgia Youth Camp (NGYC) is proudly an INDEPENDENT BAPTIST YOUTH CAMP and will be governed accordingly in action of faith anddoctrine. We only use the KING JAMES BIBLE. Our music and manner of worship may be considered old fashion but we believe they are in keeping with the wordand spirit of the Scriptures.

Dress Code: PLEASE REVIEW CAREFULLY!(In general, our dress code is designed to (1) promote modesty (2) not attract sexual or lewd attention to ones body (3) not to promote worldly appearance or fadsand (4) to honor Christ!)

Ladies:No female participant is allowed to wear PANTS, SHORTS, GAUCHOS, MINI SKIRTS/DRESSES, SLEEVELESS TOPS or TOPS EXPOSING THE MIDRIFF OR BAREBACK,SUNDRESSES OR OTHER DRESSES/TOPS WITH STRAPS or LOWCUT TOPS/DRESSES.

Modest Dresses/Skirts/Jumpers that go below the knee should be worn for services. SKIRT-APPEARING culottes that go below the knee are permitted for all dayactivities. Young Ladies that do not desire to wear culottes will feel comfortable with FULL skirts that reach mid-calf for all activities. Sneakers should be worn forday activities. Please pack at least a couple of dark blue/black T-shirts to wear for designated relay competitions (like water balloon toss) to ensure Christianmodesty. Note: Ladies please wear blouses or tops that do NOT have such a short tail that you expose yourself when kneeling or bending as a general rule, ifyou are pulling on your top constantly, it is too short.

****Please maintain decency in the dorm public areas as well.

Gentlemen:No male participant is allowed to wear SHORTS or SWEAT PANTS in public at any time (Wind Pants are acceptable). Shirts must be worn at all times. NOTANKTOPS, SLEEVLESS SHIRTS, MUSCLE SHIRTS or CUTOFFS are permitted. MALES are NOT permitted to wear Skinny Jeans which creates an unacceptableappearance.

Young Men should wear nice jeans or slacks and a comfortable shirt with a collar for the services. (While not prohibited, T-shirts are not preferred for theservices. Button up Shirts and Ties are not required, but are always appropriate.) Jeans should be worn for all day activities with comfortable T-shirts andsneakers.

****Please maintain decency in the dorm public areas as well.

ALLT-shirts and hats/caps worn at camp should not have questionable words, advertising (i.e. Country or Rock entertainers, alcohol, tobacco products, etc), orinappropriate pictures. Ideal T-shirts would include those promoting your home church or school. Boys will not be permitted to wear caps in the dining hall ortabernacle and the cap should be worn naturally and not in a fashion favoring the world.***Jewelry is best left at Home!

SWIMMING ATTIRE If the opportunity presents itself for the group to enjoy a time of swimming or water activities you will be notified of the expected dress.Here are some general guidelines if we separate the group male/female such as pool swimming and privacy is guaranteed swim suits are permitted (one piecefor females, no bikinis for either gender). If the group is not separated and not exclusively private such as the ocean, tubing or water games FULL CLOTHING willbe required. Swim suits may be worn under the clothing -- Dark Shirts will be required for male and female participants. Females should wear Dark Culottes orpin a dark, full skirt males should wear dark pants or jeans. As a reminder, when the camp uses a public pool, we cannot guarantee the gender of life guardsOR prevent pool personnel of the opposite gender from entering the pool area. If this is a concern, please wear full clothing in the pool.

Discipline: All camp activities are designed to be a fun experience for all participants. Activities are also designed to allow you an opportunity to draw closer tothe Lord and hear HIS voice not affected by normal hindrances. Please observe the following general rules of conduct:

NO CIGARETTES, SNUFF or OTHER TOBACCO PRODUCTS are permitted (youth and adults). No Drugs, Firearms, Fireworks, Radios, Alcoholic beverages, Rock Music,Country Music, CD Players, Tape Players, Record Players, TVs, Video Games (and machines), Computers, Palm Devices, knives, guns, or other weapons arepermitted. No magazines or Books please. (Exception: a personal devotional book such as Baptist Bread or similar that the participant generally uses day byday would be acceptable.) Cell phones are permitted, but MUST be surrendered to your Counselor who will control phone usage. Your days will be very full.

THE CAMP PHONE WILL BE OFF LIMITS TO CAMPERS. IN THE EVENT OF AN EMERGENCY, A CAMP COUNSELOR WILL CONTACT THE PARENTS. THANK YOU.

CAMP ACCOMODATIONS: Room and Bed assignments are made at the discretion of the camp staff. CAMPERS are NOT PERMITTED to change rooms without thepermission of CAMP STAFF. Attending Chaperones are NOT allowed to make rooming changes for their groups without the permission of CAMP STAFF. The campconducts full bed counts nightly for the safety of our campers and staff and your FULL PARTICIPATION is required. FAILURE TO FOLLOW THE DIRECTIVES OF CAMPSTAFF REGARDING ROOMING ASSIGNMENTS IS GROUNDS FOR IMMEDIATE DISMISSAL FROM CAMP. In addition lights out times are assigned daily. At thistime campers are to be in their respective rooms, quite, with lights extinguished. If a camper is found outside of his/her room after lights out they can bedismissed from camp.

Rules will be explained during orientation. Curfews and other key times will be announced throughout the event. Participants are expected to follow thedirectives of the Director, Counselors, and Chaperones at all times. NO ONE is permitted to leave the property or assigned areas. Good Sportsmanship is always aChristian grace to be exhibited by all. You should come ready to participate both in the letter of the activities and the spirit of the activity as well. THIS WILLTRULY BE WHAT YOU MAKE OF IT!

PATICIPANTS WILL ATTEND ALL SERVICES AND ACTIVITIES. ADULTS ARE EXPECTED TO ATTEND ALL SERVICES.Those refusing to participate or follow the rules established by the Camp Directors, including the dress code, may be dismissed. Parents/Guardians will becontacted to pick up the dismissed participant.

MK Consent and Release 2015

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