Blue Rose Mission
524-3762
Main Street UMC
525-4380
2015 Blue Rose Mission
Phone: (419)
GROUP WORK
Fax: (419)
230 South Main Street
APPLICATION
web: www.bluerosemission.org
Mansfield, Ohio 44902
E-mail: [email protected]
Group Name: ___________________ Group Leader's
name_______________
Address: _________________________________City:
_________________
State: _____ Zip: _____ Organization phone: ________________
Group Leader’s home/cell phone: _____________ Email:________________
Arrival Date: _______ Departure Date: _______
Total number of Missionaries:
Number of Youth 12-18 years
(M) _____ (F) _____
Number of Young Adults 19-24 years (M) _____ (F) _____
Number of Adults 25+ years
(M) _____ (F) _____
Will you be taking Wednesday afternoon or all day Wednesday off
as a "Fun Day?" _______
Rate Schedule:
$300 for full week = Sunday PM arrival to Saturday AM departure
Fee schedule listed below:
To register
•
•
•
•
Deposit due: March 15, 2015 is 25% total estimated costs of
Approximate numbers of participants
Deposit due: April 15, 2015 is additional 25% additional total costs
(50% of Total)
Deposit due: May 15, 2015 is additional 25% total costs of
verified participants (75% of Total costs) Please Revise your participant
numbers, if needed, for accuracy and check that the breakdown of youth/
adults and males/females is correct. The Blue Rose Mission needs accurate
figures to assign appropriate sleeping arrangements. also, at this time, it is
important to have final T-shirt sizes for the mission team to assure
availability for your teams arrival.
Remaining 25% due at arrival dates along with all ORIGINAL forms are
due.
$55 per person per night includes: Breakfast, Lunch, and Evening Meal, and a Tshirt provided.
$35 per person for one day event with Light Breakfast, packed Lunch, Afternoon
Snack, and T-shirt provided.
$10 per person for additional overnight lodging.
Group App pg. 1
Revised 9/4/2015
Please indicate if there is a specific type of project that may be of
interest to your group, considering the group's talents:
FIRST
CHOICE__________________________________________________
SECOND CHOICE
________________________________________________
Describe the skill levels of your group for each of your above choices?
____________________________________________________
____________________________________________________
____________________________________________________
___
“God doesn’t call the qualified. He qualifies the called.” -unknown
* Blue Rose Mission will be diligent in attempting to match skills to
work assignments as best we can within the realities of the Requests
of the homeowners.*
Freewill offerings are accepted for project materials.
PLEASE ADVISE US OF ANY SPECIAL DIETARY NEEDS (food
allergies, vegetarian, etc.) ____________________________
______________________________________________
______________________________________________
ALL MINORS MUST BE UNDER THE SUPERVISION OF A DESIGNATED
ADULT. Boys are to stay out of the girls’ dorm and girls are to stay out of
the boys’ dorm unless they are accompanied by an adult(s) for the purpose of
Bible Study or group gatherings.
__________________________________________________________________________
SIGNATURE OF PERSON COMPLETING APPLICATION
DATE
We are asking each group to purchase their own insurance to cover you while you are
participating in the Blue Rose Mission. We suggest the use of North Central
Jurisdiction's Insurance: http://www.umvimncj.org/NCJVIM/Forms.html
Group App pg. 2
AT-HOME CONTACT PERSON
The At-Home Contact Person is expected to have a list of everyone attending Blue Rose
Mission and who to contact in case of an emergency or delay. While at Blue Rose Mission, if
the group experiences an emergency, if a minor’s parents cannot be reached, or if the
group is delayed in the departure from the Camp, the At-Home Contact Person will be
contacted with the information.
GROUP: _________________ NAME OF CONTACT PERSON:
____________________
DAY PHONE: ___________ EVENING PHONE: ____________ CELL: ______________
ADDITIONAL NAME / PHONE NUMBER IF ABOVE PERSON CANNOT BE REACHED:
__________________________________________________________________
__________________________________________________________________
__
Please return this form to Blue Rose Mission. Make sure the contact person has a list of
team members and phone numbers, a copy of this form, Blue Rose Mission contact
information, and the name of the person in charge of your group. Thank you.
****************************************************************************************
2015 Blue Rose Mission
T-SHIRT ORDER FORM
Please indicate the number of Blue Rose Mission T-shirts you would like.
Adult SM _____ Adult MED _____ Adult LG _____
Adult XL _____ Adult 2XL _____
T-shirts will be as a part of the registration fee at the Blue Rose Mission.
PLEASE NOTE: Orders must be received no later than 30 days before your work
camp to ensure T-shirts are ready upon your arrival.
Group App pg. 3
Revised 9/4/2015
AVAILABLE SUMMER 2015 WORK DATES:
Weeks available are as follows:
June 14-20, 2015
June 21-27, 2015
June 28-July 3, 2015
July 5-11, 2015
July 12-18, 2015
July 19-25, 2015
July 26-Aug 1, 2015
Aug. 2-8, 2015
Aug. 9-15, 2015
Aug. 16-21, 2015
DINING & HOUSING FACILITY LOCATION
will be
Light & Life Christian Camp (aka MCCM, Inc.)
1246 Lucas Road, Mansfield, OH 44905
Contact Blue Rose Mission for other available work plans,
single day, full weeks, or other times of the year.
Group App pg. 4
THINGS TO DO BEFORE YOU COME
__ Has each team member read and signed the Covenant?
__Have you completed & signed the necessary forms: Health Form with insurance
information, Liability Release, Covenant and Safety Policy? Have you mailed a copy
of the required forms two weeks prior to your arrival date?
__Is the original Medical Information sheet available for team leaders to carry
while at the worksite?
__Have you obtained parental consent and signatures on your minors’ (age 12 to 18)
forms?
__Do your team members have appropriate clothing and tools?
__With youth, do you have enough adult supervision? An adult is age 25 or older.
The requirement is 1 male and 1 female adult per 5 youth ages 12-18 and 1
adult (either gender) per 10 young adults ages 19-24.
__Do all parents and someone at your church know the emergency telephone
number to reach your group?
__Do you have adequate money for your trip, gas, food, souvenirs, and
emergencies?
__Are you planning outings that will require advance tickets? Have you ordered
these? Refer to link on our website to the Mansfield Area Chamber of Commerce
for available activities.
__Are you preparing your team members to be flexible to changes in work
assignments, realizing that not all work is fun? Do they have open minds and
broad expectations for the trip? Will they be ready to be the hands and
feet of Christ by demonstrating His Love through their work to meet people
in their brokenness?
__Have you asked a team member to be the photographer and another to be the
journalist? Depending on the size of your group, you may need more as
teams may go to multiple work sites at the same time.
__Do any team members have food allergies or special food requirements
(Vegetarian, peanut allergies, etc.) that you need to inform us about?
Group App pg. 5
Revised 9/4/2015
Blue Rose Mission
INDIVIDUAL HEALTH FORM
To be completed by each person in the Work Mission Program. Please print clearly.
Name of Group: __________________________ Dates attending Work Mission: _______________
Participant Information
Name: ____________________ Date of Birth: ___/____/____ Phone: (____) _____________
Male / Female
Street Address: ______________________________ City: ______________ State: ____ Zip: _______
Work Team Leader: _____________________________ Phone (_____) __________________
Parent/Guardian/Spouse Information
Spouse Name: ______________ Home Phone: (_____) ____________ Day Phone: (____) _________
Mother’s Name: ____________ Home Phone: (_____) ____________ Day Phone: (____) _________
Father’s Name: _____________ Home Phone: (_____) ____________ Day Phone: (____) _________
If Parent/Guardian/Spouse is not available in an emergency, please notify:
Name: _____________________Relationship: ___________________Phone: (____) _____________
Health Information
Medications: __________________________________________________________________________
Allergies: _____________________________________________________________________________
Reaction: _______________________________________________________________________________
Dietary Needs: __________________________________________________________________________
Other Allergies (food, hay fever, insect bites, asthma, etc):
_____________________________________________Reaction: _____________________________________
Current Medications used: _____________________________________________________________
Last Tetanus/Booster Date: ___________________ (if over 5 years ago, check with your physician)
Insurance Co.: __________________ Policy No.: _______________ Phone: (_____) ________________
Family Doctor: _________________________________ Phone: (_____) ____________________
Do you or this youth have any conditions that would prevent full participation in this program?
[ ] YES
[ ] NO
If yes, please explain:
__________________________________________________________________________________
PERMISSION AND EMERGENCY MEDICAL AUTHORIZATION
In the event the above person is unable to answer for themselves or is under 18 years of age and
the parent or guardian cannot be reached, permission is hereby granted for necessary emergency
medical treatment by a certified first aid person and/or a licensed medical professional.
Signature:
__________________________________________________ Date: ________________________________
(Circle one) Parent/Guardian/Adult Participant
One copy of this form is to be sent to the Blue Rose Mission. The original form is to be
kept with the participant in the vehicle en route to/from and during his/her stay.
INDIVIDUAL FORM pg. 1
Blue Rose Mission
INDIVIDUAL LIABILITY RELEASE FORM
Participant’s Name: _____________________________ (known as the “undersigned”)
Group Name: ________________________Work Mission Dates: _________________
The undersigned releases and agrees to hold harmless the Blue Rose Mission, the Light
and Life Camp, Richland Rural Life Center, the East Ohio Annual Conference of the United
Methodist Church, the local churches and their members, employees or agents, from any
liability, injury, damages, loss, accidents, delay or irregularity related to the undersigned
individual’s planned participation or involvement in the following project:
Blue Rose Mission
Main Street UMC
230 South Main Street
Mansfield, Ohio 44902
Phone: (419) 524-3762
Light & Life Christian Camp (aka MCCM, Inc.)
1246 Lucas Road, Mansfield, OH 44905
This release covers all rights and causes of action of every kind, nature and description,
which the undersigned ever had, now has, or but for this release, may have. This release
binds the undersigned and his or her heirs, representatives and assigns.
_____________________________________________________________
Signature of: (circle one) Parent / Guardian / Adult Participant
________________________________________ __________________
Please Print Name
Date
INDIVIDUAL FORM pg. 2
Revised 9/4/2015
Blue Rose Mission Covenant, Safety Policies & Procedures
It is the plan of Blue Rose Mission staff that you have a good experience
while participating in Blue Rose Work Mission. We want you to have a
safe experience!
1. Remember that “safety” is a watch-word of Blue Rose Mission! Group safety is a
high concern for the staff of Blue Rose Mission.
2. Each group is to take a first aid kit with them to the worksite. First aid kits are
provided by Blue Rose Mission.
3. Realize that persons can have accidents. If an accident should occur, alert your project
supervisor and group leaders immediately.
4. No one is to climb up a ladder without someone at the base making sure that the ladder
is secure. Take no unnecessary risks!
5. No alcohol, drugs, "highly concentrated Caffeine" drinks, or other illegal substances.
Prescription drugs must be clearly labeled.
6. Pay careful attention to instructions given to you by Blue Rose Mission staff and group
leaders. On the worksite, follow the instructions of and advise any changes to the
project supervisor.
7. If you feel uncomfortable with doing a certain task, let the project supervisor know.
Ask questions if you do not know how or what to do next. There are no dumb
questions!
8. Wear modest clothing - shoulders covered, jeans or loose fitting shorts that are long
enough, work boots or sensible shoes, and use gloves on the worksite.
9. Drink plenty of water while at the worksite, especially on hot days.
10. Make sure you rest during break times to regain your strength.
11. Use sunscreen for outside work or play.
12. Foul or undesirable language is not permitted.
13. Keep workspace and living space neat and clean.
14. Don’t criticize, speak unkindly, gossip, or start rumors.
15. You grant and convey to Blue Rose Mission all rights, title and interest in any and all
photographic images taken by Blue Rose Mission staff during your time as a missionary.
In the scriptures, we have the concept of a covenant. A covenant is a promise, an agreement
between two or more parties. We ask you to be in covenant with God and Blue Rose Mission
during your time as a missionary. By signing this covenant, you make an agreement between
God, Blue Rose Mission, and yourself to abide by Blue Rose Mission Worksite rules. If you
break this covenant, your family will be notified. If disciplinary action would need to be
taken, and you were to be sent home, it would be at your own expense.
I have read and understand the above Covenant. By signing this Covenant, I agree to abide by it
while participating at Blue Rose Mission. Please return form to Blue Rose Mission.
Participant’s Name (please print):______________________ Group: ____________________
Participant’s Signature ___________________________ Date ____________________
Parent’s Signature (if participant is under 18) _________________ Date_____________
Parent’s Printed Name
____________________________________
Remember to Bring with You...
INDIVIDUAL FORM pg. 3
__Each participant’s original Individual forms are due upon arrival
__Any tools / materials, we contacted you about ahead of time
__Personal Bible
__Camera
__Flashlight with spare batteries
__Musical instrument(s) for spare time
__Watch/alarm clock
__Fan
__Sleeping bag/twin sheets/blanket/pillow
__Toiletries
__Washcloths and towels
__Swim suit, beach towel for a fun night at the pool
__Rain gear
__Work clothes – 1 set per person minimum that includes the following:
long pants, long sleeved shirt, work shoes/boots, work gloves, work hat
__Changes of clothes for after work
__Disposable face masks (may be a team item)
__Safety goggles (may be a team item)
__Insect repellant
__Sunscreen
__Individual reusable water bottle
__3-5 gallon jug/cooler for the team drinks at worksite
We ask that your group bring one or more Bibles to give to your client at the end of
the project. Each member of the group will sign the Bible and present it to the
client.
The main goal of Blue Rose Mission is to tend to the spiritual needs of the homeowner, not
just the physical.
Have a good spirit and a positive attitude so that you are ready to serve God by
serving others!!
INDIVIDUAL FORM pg. 4
Revised 9/4/2015