INFORMATION AND MEDICAL RELEASE FORM

This will remain with the Coordinator and the Work Team at the site

Name:___________________________________ Phone:______________ DOB:______

Address:________________________________________________________________ Street City, State Zip

Church name:________________________________ Phone:_________________

Who should we contact in case of an emergency?

Name:_______________________________________ Phone:_____________ Relationship:_______________________________________

Allergies and Medications:__________________________________________________

Special Health Concerns:___________________________________________________

Health Insurance Co.:____________________ Policy #:____________ Phone:________

Primary Insurance Holder:____________________ Employer:_____________________

Primary Doctor:_____________________________ Phone:_______________________

I hereby give my permission to have my son/daughter treated by competent medical personnel as a result of accident or medical emergency while involved in the Joe Rush Center for Urban Ministry, Inc. In the event of an emergency and after reasonable attempts to contact me (us) at the above listed phone numbers have been unsuccessful, I hereby give permission to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery (under recommendation of a qualified doctor) for my child/ward/self (if over 18) to the following priority order: 1.) ______________________

2.)______________________________ 3.) Physician selected by Urban Ministry Inc. I also agree that my insurance will be used for such medical care and I am aware that I will be billed for any medical care not covered by my insurance.

Signed:_______________________________________Date:____________

STATEMENT OF ACTIVITIES AND RELEASE

The Joe Rush Center for Urban Mission is a painting program administered through Urban Ministry, Inc. Volunteers for the Rush Center may use hand tools such as scrapers, hammers, and lawn keeping devices. Activities may include climbing up and down ladders with and without supplies, tools, and other materials. Many of the homes on which Urban Ministry works were built before 1978, and therefore may have paint that contains lead. Necessary precautions are offered by Urban Ministry to avoid inhalation or ingestion of lead paint chips and/or dust.

Volunteers may, in their free time, engage in non-sponsored activities, i.e. sports, or other activities of their choosing. The Rush Center may sponsor some recreational activities including swimming, softball, Frisbees, ect. Volunteers are not required to engage in any work or recreational activity in which they feel they are not able to safely participate. Special medical conditions must be communicated to the Rush Center .

I______________________________ have read and understand the above statement of activities and information material and understand the extent and nature of the activities in which I will participate and hereby release and discharge Urban Ministry, Inc., its agents, employees and any and all persons connected therewith from any and all liability claims and causes of action of any type arising from or connected to my participation in the activities of Urban Ministry, Inc.

I hereby consent to be treated by competent medical personnel as a result of any accident or medical emergency while involved in the activities of Urban Ministry, Inc.

________________________________________ Date______________________

Signature of Participant

________________________________________ Date_______________________

Signature of Parent/Guardian (if Minor)