Mission Outreach Volunteer Registration form by Ricky Hill | Nov 3, 2023 | Latest News Mission Outreach - Volunteer Registration MISSION OUTREACH - VOLUNTEER REGISTRATION Church/Group Name * Dates Attending * Group Leader's name * Group Leader's email * Participant Name * Participated with HRLC before? * Yes No Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Phone * Can you receive text messages on this phone? * Yes No Email * Date of birth (mm/dd/yyyy) * EMERGENCY MEDICAL INFORMATIONMedical information on this form will remain confidential and will only be used if medical treatment is needed. It will be used for noother purpose. Have you had a Tetanus shot? Yes No If yes, how recent? 0-1 years 1-5 years 5-10 years Please list all medication(s) you currently take (prescribed & over-the-counter) If this does not apply, please type in 'none' List any medication(s) you CANNOT take If this does not apply, please type in 'none' Please list any allergies and/or special heath problems or concerns If this does not apply, please type in 'none' MEDIA RELEASE I hereby grant permission to Hinton Rural Life Center to use photographs, videos, social media posts, and/or any other media of me/my dependent for promotion and publicity purposes. Permission is granted for the use requested. Signature of adult participant or parent/guardian * signature keyboard Clear Date signed * Provide the email of the person completing this form. You will be emailed a copy when you 'submit' the information. * **If permission is not granted, it is the responsibility of the Group Leader to inform Hinton staff verbally upon arrival. ***IF VOLUNTEER IS UNDER 18 YEARS OF AGE: Parent/Guardian Name Also at Hinton? Yes No Cell Phone Home Phone Work Phone Parent/Guardian Name Also at Hinton? Yes No Cell Phone Home Phone Work Phone PLEASE BRING A COPY OF YOUR INSURANCE CARD AND KEEP A COPY OF THIS FORM IN THE VEHICLE WITH THE PARTICIPANT AT ALL TIMES. If you are human, leave this field blank. Next
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