1. education
2. school

CitySERVE 2015
Saturday, May 2
8:00 am - 4:00 pm
Serve God. Bless the City. All in One Awesome Day!
$20 per person plus canned food donation
($15 for additional family members)
Join 500+ participants for service projects at 40+ sites across the city. Projects include:
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Light carpentry and painting
Landscaping, weeding, gardening
Schedule
8 am - Check-in at Lutheran West High School
(3850 Linden Road, Rocky River). Meet your team
members, receive your t-shirt and a boxed lunch.
8:30 am - Fellowship, short message and praise
music to get motivated for the day of service.
9 am - Depart for work sites by bus or carpool.
9:30 - 3:30 - Service projects throughout the city.
4 pm - Return to LW and walk your choice of 1,2,3
miles to benefit the Hunger Network of Greater
Cleveland. Plus, enjoy tasty food hot off the grill!
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Cleaning, sorting and sewing projects
Ministry to inner city children and families
Register today!
New this year! Registration forms are ONLINE and can
be downloaded at:
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www.lutheranwest.com
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www.buildinghopeinthecity.org
Return your completed Registration Form with payment
to Building Hope in the City or Lutheran West High
School by April 17. Your space cannot be reserved
without registration and payment.
Call 216.281.4673
“Like” Building Hope in the City on Facebook and post your pics with
#cityserve2015
CitySERVE 2015
May 2nd
Registration Form
(Please make additional copies of both sides as needed.)
Name: __________________________________________________________________ Age: ____________
Address: ____________________________________ City: _______________________ Zip: _____________
Email Address: ____________________________________________________________________________
Home Phone: _______________________________________
Cell Phone: _________________________
CitySERVE Work Project
I’m willing to do the following (check all that apply):
garden/landscape
carpeting/construction
clean
minister to children
minister to elderly
sort/organize
paint
sew
CitySERVE “Walk for Hunger”
I will return to LW after my work
project to walk:
1 mile
2 miles
3 miles
I’m willing to drive to my assigned site from LW. I could drive ____ additional people.
(Must be at least 21, and must sign driver’s release on reverse side of this form.)
Please bring one canned food item with you when you report to LHSW at 8:00 a.m. on May 2nd.
Registration Cost/Information
Individual participants: $20 each = $_______ (total enclosed)
*Families: $20 first member + $15 for additional members = $________ (total enclosed)
*Family members must register together to be eligible for the discount.
Please enclose payment with registration form(s).
Either mail to: Building Hope in the City, 2031 West 30 Street, Cleveland, OH 44113
or drop off in the school office at Lutheran High School West.
Please make checks payable to: Building Hope in the City.
CitySERVE cannot guarantee your spot without pre-registration and payment.
Registration deadline is April 17th.
Please indicate which group (if any) you would like to work with. We will work to assign groups
together, however there is no guarantee that all requests can be met. _______________________
____________________________________________________________________________________
____________________________________________________________________________________
Please complete the Medical Release/Consent Form on the reverse.
BOTH sides of this form MUST be completed by ALL participants.
Medical Release and Consent Form
MEDICAL RELEASE: I/we, the undersigned, are the parents or the legal guardians of _______________________________,
a minor, and have given consent for him/her to attend CitySERVE 2015 being coordinated by Building Hope in the City (BHITC)
and Lutheran High School West (LHSW) on May 2, 2015. If it is necessary or desirable that I/we/our youth named above be
provided medical treatment, BHITC, LHSW, its agents or representatives are hereby authorized to provide and/or seek medical
attention, including, but not limited to, first aid, cardio pulmonary resuscitation, professional emergency medical care and
otherwise. I/we agree to be financially responsible for the cost of any medical care afforded to me/us/our youth, and will hold
BHITC, LHSW harmless from any demands for such costs.
LIABILITY RELEASE: I/we understand that there are inherent risks involved in any youth event, and I/we hereby release BHITC, LHSW,
their agents, and volunteer workers from any and all liability for any injury, loss, or damage, to person or property that may occur
during the course of my/our involvement with CitySERVE 2015.
TRANSPORTATION RELEASE: I/we understand that LHSW and its designated pick-up and drop-off locations cannot and do not serve
as an insurer of participant’s safety, and that, whether through the negligence of LHSW, its pick-up/drop-off locations, third parties
or otherwise, accidents can and sometimes do happen. In consideration for allowing participants to take part in LHSW bussing,
I/we release and agree to hold harmless LHSW, its pick-up/drop-off locations, its agents and representatives from and against any
and all liability or responsibility for injury or damages caused to participants in connection with this transportation. I/we further
recognize that to expect or call upon LHSW to accept responsibility and/or assume liability for such potential injury or damage
could result in such additional costs to LHSW that bussing may not be offered in the future.
PHOTO RELEASE: I/we consent to and authorize the use and reproduction, in print or electronic format by LHSW, BHITC or anyone
authorized by these organizations, of any and all photographs and audio and visual recordings which have been taken on this
day for marketing purposes, without compensation.
FOR THOSE UNDER 18 YEARS - Release/Consent Signatures
Participant’s Name
Parent/Guardian Name
Participant’s Signature
Signature
Date
ADULT PARTICIPANT RELEASE – Release/Consent Signature
Participant’s Name
Participant’s Signature
MEDICAL EMERGENCY INFORMATION
Health Insurance Provider
Policy/Group Number
Doctor’s Name: ____________________________________________________________________________
List of allergies/medication needs: _________________________________________________________
Emergency Contact Name
Emergency Contact Number(s)
Relationship to Participant
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DRIVER’S RELEASE: As a driver for CitySERVE 2015, I recognize that, in the event of an automobile accident
chargeable to me, my vehicle insurance will be considered the primary coverage for all claims, judgments, and
liability for any injury and damage to any and all persons that I may be transporting to and from a work site. I attest
that I am currently at least 21 years of age and have a current and valid driver’s license that is in good standing
with the State of Ohio. I carry automobile insurance coverage that provides for minimum liability coverage of
$100,000 per individual and $300,000 per occurrence to cover any and all persons that I may be transporting and to
cover any and all claims that may arise against me.
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Signature of Driver