Official use only: Presbytery of Detroit Katrina Relief Trip 12 New Orleans, LA, April 9-17, 2011 _________________________________ _ —APPLICATION— APPLICANTS MUST BE AT LEAST 16 YEARS OLD BY DEPARTURE DATE & HAVE HEALTH INSURANCE COVERAGE (See page 2 of 2) A parent must accompany participants less than 18 years old. HOW TO BOOK YOUR TRIP 1. Contact Us: Ask questions and check availability with trip coordinator Julie Smith at (248) 821-8216, or [email protected]. 2. Cost: $185 per person which includes PDA fees, in camp meals and in transit lodging. The application and $185 fee are due Sunday, March 20, 2011 (the Orientation Meeting date) and the fee is non-refundable thereafter. 3. Application: Mail completed application with a check payable to the Presbytery of Detroit for the full payment of $185 to: Katrina 12 Trip, c/o Julie Smith, 99 Wayne St., Pontiac, MI 48342 ([email protected], 248-821-8216). You will receive an email confirmation of your registration when the application and check are received. 4. Orientation Meeting: Sunday, March 20, 4:00 PM, at First Presbyterian Church, 99 Wayne St., Pontiac, MI 48342 5. Travel: Participants will carpool in personal vehicles from the Detroit area & are responsible for fuel and in-route meal expenses. Name: Last________________________________ First ________________________ Preferred/Nick ________________________ Address_____________________________________ City/State/Zip_______________________________________ Gender ______ E-Mail Address (Important):__________________________________________________________ Birthdate _________________ Phone: Home__________________________ Work__________________________ Cell ___________________________________ I allow my photograph & name to be used on our website to chronicle our mission trip. YES  is assumed unless you check NO  Leading Devotions , Check areas of interest: Journaling , Reporting , Photography , Blog Publishing . Check communications equipment you will bring: Digital Still  or Video Camera  with USB cable, Wireless-Enabled Computer Do you want to work in New Orleans, LA  or Pearlington, MS  ? If neither is checked you will work in New Orleans. TRAVEL & HOTEL ARRANGEMENTS Are you driving: YES or NO? If yes, provide the make and model of your vehicle: __________________________________ How many people can you take (including yourself) with luggage? _______________________ Make motel reservations for me on the way South to LA (Check: YES  or NO ) and North to MI (Check: YES  or NO ) Rooms are double occupancy. Name your preference for a roommate: _________________________________________________ SKILLS ASSESSMENT Show skill level using these numbers in boxes below: 1-Willing to try; 2-Can do with guidance; 3-Do well First Aid/CPR Skills Cook Pastor, YES or NO Landscaping Roofing Priming/Painting Masonry/Brick, Plaster Tile: ceramic, etc. Flooring, vinyl, etc. Flooring: Laminates Cabinet Installation Door Installation Window Installation Siding Drywall Finishing Drywall Hanging Insulation HVAC Plumbing Electrical Finish Carpentry Framing Carpentry Remove drywall/floors Foundation Lead work crew, Y / N independently; 4-Do well and guide others; 5-Work in trade. I am comfortable on a (check all that apply): Ladder , Roof , Raised Deck  Other skills and abilities: ______________________________________________________________________________________ Any work limitations (things you must avoid)?: ____________________________________________________________________ Page 1 of 2 Presbytery of Detroit Katrina Relief Trip 12 New Orleans, LA, April 9-17, 2011 Official use only: _________________________________ _ SUPPLEMENTAL MEDICAL INFORMATION PURPOSE: This form is kept by the camp nurse. Its sole purpose is to alert the Trip Leader and medical providers to any condition that might assist in your care in an emergency medical situation. All information on this form will be kept confidential and the form will be kept on file at the presbytery offices at the conclusion of the trip. Participant name: ____________________________________________________ DOB_________________________ Church /Organization Name__________________________________________ Phone__________________________ Church /Organization Address ________________________________________________________________________ Please describe any dietary restrictions_________________________________________________________________ _________________________________________________________________________________________________ Do you have any physical conditions that could be a health/safety factor at any time during this trip? (Check) NO  or YES If yes, please describe: ___________________________________________________________________________________ ______________________________________________________________________________________________________ Please list prescription medications for any condition described above: ____________________________________________ ______________________________________________________________________________________________________ Medical Insurance Provider __________________________________Policy #__________________________________ Address ______________________________________________________________________________________________ Phone Number_________________________ Name of primary insurance holder: __________________________________ **BRING YOUR MEDICAL INSURANCE CARD WITH YOU** ***Medical insurance is available for the mission trip, through the Presbytery. Please check the box if you do not have health insurance of your own and need the Presbytery to provide it for you.  Participant Signature_________________________________________________ Date______________________________ The next three pages are separate forms required by PDA. Unfortunately, there is some duplication of information but it is important to complete these forms in entirety. Page 2 of 2 Presbytery of Detroit Katrina Relief Trip 12 New Orleans, LA, April 9-17, 2011 Official use only: _________________________________ _ Volunteer Information and Release form Thank you for volunteering with Presbyterian Volunteer Villages. Teams like yours are making a difference across the country as you share the love of Christ by giving of your time and service to help families clean up and rebuild. Please complete the following information. This provides PDA with a record of your volunteer work and allows us to send you 1) a letter or certificate acknowledging your volunteer service and 2) Mission Mosaic, a semi-annual update (in magazine format) of how Presbyterians are responding to disasters around the world. This form also includes required release information and must be completed before your participation in the village begins. Please legibly PRINT the following information: Check one: Mr. Mrs. Ms. Rev. Other ____________ Name (first and last) ____________________________________________________________ Email address __________________________________________________________________ Would you like to receive PDA Rapid Information Network (PDA-RIN) email updates on disaster responses? We encourage you to share the information with your congregation. Yes No Phone numbers (please specify if home/office/cell) _____________________________________________ Mary Lloyd, Presbytery Contact Who is your Team Leader on this volunteer mission ____Julie Smith, Mission Team Leader____ (person who organized the trip and contacted PDA) What group are you volunteering with? (the church, presbytery, or organization your team is part of) Organization Name ______Hands-On Mission Work Group, Presbytery of Detroit_____________ City/State/Zip ____17575 Hubbell, Detroit, MI. 48235__________________________________ Team Leaders please also include: Organization Street Address __17575 Hubbell; Detroit, MI. 48235___________________ Organization Phone# ________313-247-0792____________________________________ Which village are you assigned to ______Olive Tree_________________________ Arrival Date in the village __April 10, 2011_______ Departure Date ___April 16, 2011__________ Have you been to a Presbyterian Volunteer Village before? If yes, when and where? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Please continue to the next page for required release information and signatures. PDA General Release and Volunteer Information Form - 07/09 Page 1 of 3 Presbytery of Detroit Katrina Relief Trip 12 New Orleans, LA, April 9-17, 2011 Official use only: _________________________________ _ GENERAL RELEASE, INDEMNIFICATION AGREEMENT AND AUTHORIZATION FOR MEDICAL TREATMENT Participant name: _________________________________________________(“Participant”) DOB: __________________________________ Home Address: ______________________________________________________________________ City/State/Zip: ______________________________________________________________________ Telephone: (Cell) __________________________ (Day/Evening)______________________________ E-mail address _____________________________________________________________ In consideration of the opportunity provided to me to participate in the PDA Disaster Response and any services, housing, food, and the like provided by PCUSA (as defined below), I, Participant, hereby understand and agree that the Presbyterian Church (U.S.A.) General Assembly, all synods, presbyteries, and local churches and their corporations and related entities, their staff, volunteers, directors, officers, agents, elders, deacons, representatives, successors, assigns and entities (hereinafter collectively referred to as "PCUSA") will not be responsible in any way whatsoever for loss, damage, or injury of any kind or in any manner resulting from or in connection with my participation in PDA Disaster Response. I, Participant, understand and agree that PCUSA does not and cannot guarantee my safety in connection with the PDA Disaster Response. Further, I understand and agree the activities involved with the PDA Disaster Response may include but are not limited to the following: difficult living conditions, risks concerning means of travel, food, water, diseases, pests, poor sanitation, and other health related situations, including potential injury while working. I accept and assume all responsibility for all risks which may occur during, in connection with, or result from my participation in the PDA Disaster Response including, but not limited to, potential injury while working. RELEASE: With the above in mind and by my signature below, I fully understand, agree and hereby voluntarily release and forever discharge PCUSA. PCUSA shall not be responsible or liable in any way for any accident, loss, death, injury or damage to myself or my property, in connection with my participation in the PDA Disaster Response or any portion of the PDA Disaster Response even if said injury or action is due to the alleged negligence of PCUSA. Further, I do hereby agree to indemnify and hold PCUSA harmless against any and all liabilities, damages, claims, actions or rights of action, suits, judgments and associated costs and expenses (including, without limitation, attorneys' fees) of whatsoever kind in connection with my participation in the PDA Disaster Response or any portion of the PDA Disaster Response. Further, I make this agreement on behalf of my heirs, agents, fiduciaries, successors and assigns. I waive, knowingly and voluntarily, each and every claim or right of action I have now or may have in the future against the PCUSA related to my participation in the PDA Disaster Response, even if any such claim or right of action is caused by PCUSA's alleged negligence. This document does not release PCUSA from gross negligence. PDA General Release and Volunteer Information Form - 07/09 Page 2 of 3 Presbytery of Detroit Katrina Relief Trip 12 New Orleans, LA, April 9-17, 2011 Official use only: _________________________________ _ MEDICAL COVERAGE: I understand and acknowledge that no medical or other insurance or health care benefits will be provided to me by PCUSA during my participation in the PDA Disaster Response, and I certify that I have sufficient health, accident and liability insurance or other benefits to cover any bodily injury or property damage I may incur while participation in the PDA Disaster Response and to cover bodily injury or property damage caused to a third party as a result of my participation in the PDA Disaster Response, as follows: Company ________________________________________ Policy #__________________________________ Address ___________________________________________________________________________________ MEDICAL RELEASE: I hereby state that I am in good health and have all medications necessary to treat any allergic or chronic conditions, and I am able to administer such medications without assistance. If at any time during my participation in the PDA Disaster Response I need emergency medical care and am not able to give consent because of my physical or mental condition, I authorize PCUSA to make emergency medical care decisions on my behalf, and I specifically release PCUSA, in making those emergency medical care decisions, from any and all liability associated with said decisions, even if injury or death is the result of PCUSA's alleged negligence. Person to be notified in case of injury: Name _______________________________________________________________________ Telephone: _____________________________ (evening)______________________________(daytime) Cell Phone: _________________________________________ ALL PARTICIPANTS MUST SIGN: My signature below indicates that I have read this entire two page document, understand it completely, and agree to be bound by its terms. SIGNATURE OF PARTICIPANT: __________________________________________ DATE EXECUTED: ______________________________________________________ SIGNATURES MUST BE WITNESSED: SIGNATURE OF WITNESS: _____________________________________________ DATE EXECUTED: _____________________________________________________ (SIGNATURE OF PARENT OR LEGAL GUARDIAN IS ALSO REQUIRED IF PARTICIPANT IS UNDER 18 YEARS OF AGE.) SIGNATURE OF PARENT/LEGAL GUARDIAN (if applicable)_________________________ SIGNATURE OF WITNESS: _____________________________________________ DATE EXECUTED: _____________________________________________________ PDA General Release and Volunteer Information Form - 07/09 Page 3 of 3