Southern Baptist Disaster Relief

Volunteer Registration

RELEASE AND INDEMNITY AGREEMENT, MEDICAL RELEASE FORM & PERSONAL INFORMATION UPDATE

I do hereby represent and acknowledge I am entering a missionary venture with others; as a volunteer I am at least 18 years of age, I am paying my own expenses, including insurance[1], for the purpose of helping in times of disaster for hte glory of God and to demonstrate my faith in Christ; that the work my at times be hazardous and somewhat arduous and will be performed by concerned volunteers and qualified professionals trained in disaster relief work; that vehicles transporting these volunteers will be operated by licensed volunteers, who may or may not be professional drivers.

I recognize and acknowledge potential accidents at hte disaster site, involving motor vehicles, in or about the living, sleeping and eating areas, or during activities of the disaster relief team l am fully aware of possible injuries to members of the disaster relief team, including myself.

Therefore, I desire to protect, release, acquit, indemnify and hold harmless from any and all claims, injuries, damages, losses, expenses or attorney fees incurred by me, my heirs, administrators, executors or assigns.

For and on behalf of myself, my heirs, administrators, executors, assigns and all other persons, firms or corporations, I do hereby release and discharge from liability all other persons on the disaster relief team with me, those who notified, selected or assigned me to said team, the Texas Baptist Men, Inc., their employees and representatives, successors or assigns, fromany claims, demands, damages, actions, causes of actions which I, the undersigned, have or may hereafter, and on account of, or any way growing out of injuries or damages both to persons or property resulting or that may hereafter result from the voluntary venture.

This waiver, release and indemnity agreement is fully understood by me and I enter the same willingly for the purpose herein above stated.

[1] Each Volunteer is expected to have insurance in case of accident, injury or illness. Personal liability is the responsibility of the volunteer.

*Required Information
PLEASE COMPLETE ALL INFORMATION
Name *
Date of Birth* mm/dd/yyyy
DR Badge Expiration* mm/dd/yyyy
Email Address*
Home Phone () -
Work Phone () -
Cell Phone* () -
Street Address*
City*
State*
Zip*
Spouse Name
Spouse Work Phone ( ) -
Spouse Cell Phone ( ) -
Emergency Contact*
Emergency Contact Relationship*
Emergency Contact Phone* ( ) -
Secondary Emergency Contact
Secondary Emergency Contact Relationship
Secondary Emergency Contact Phone ( ) -
Church Name
Church City
Church Phone ( ) -
Church Association
Church Pastor
Church Pastor Home Phone ( ) -
Church Pastor Cell Phone ( ) -
Physician*
Physician Phone* ( ) -
Health Insurance Company*
Health Insurance Policy Number*
Year of Last Tetanus Shot*
MEDICAL HISTORY*
Allergy (explain reaction)
Broken Bone (explain)
Hepatitus C
Food/Meds/Plant/Insect
Diabetes
Kidney Disease
Asthma
Dizziness/Fainting
Mononucleosis
Back Pain
Headaches
Past Surgery (explain)
Blood Pressure HIGH
Heart Disease (explain)
Seizures
Blood Pressure LOW
Hepatitus A
Stroke
Blood Disorder (explain)
Hepatitus B
Other (explain)
Please explain the above noted health problems and any additional special medical conditions of which the Unit Leader (Blue Cap) should be aware:
MEDICATION: List medications taken on a regular basis with dosage and time to be taken. Please list each medication on its own line.

THE FOLLOWING STATEMENT MUST BE ELECTRONICALLY SIGNED. YOU MAY HAVE TO RE-SIGN A PHYSICAL FORM ONCE THE UNIT IS ACTIVIATED.

Signature *
The above information is accurate to the best of my knowledge. I understand this form will be kept by the Unit Leader (Blue Cap) for use if needed. I give permission to release information to medical personnel if necessary. Should I be unconscious, I give permission to a Southern Baptist Disaster Relief representative to act as spokesman in granting permission for emergency treatment (including anesthesia) if necessary.

Sign by indicating your email address.
Print the completed form, staple, sign and have a witness sign the physical copy. Make and keep a dual-signed copy for yourself. Hand the original dual-signed copy to your Unit Leader (Blue Cap).

Your Physical Signature:

 

 
Your Signature
Date

Witness Print Name, Signature & Date:

 

 

 
Witness Print Name Witness Signature Date



Disaster Relief Volunteer Guidelines can be obtained from your Unit Leader.