Model Love Volunteer Form- Providence Medical Clinic

Providence Medical Clinic of Kingsport was established with a mission to provide compassionate, high-quality healthcare to our community. Inspired by a vision to serve the residents of Kingsport and the surrounding areas, our clinic has grown into a trusted healthcare provider, combining advanced medical expertise with a patient-centered approach.
Project Description: Window cleaning and cleaning the kitchen.
Time: 10:00am-2:00pm
Age Limit: 12+
Remember to bring your own lunch and water!

Comments

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Name(Required)

First Last

Phone(Required)

Email(Required)

Age(Required)

Shirt Size(Required)

Are you 18 years old or older?(Required)

Yes

I am at least 12 years old.(Required)

Yes

Consent for Minor Student CF Waiver(Required)

By checking this box I agree to the terms set forth in the Waiver below and confirms that I have read this information, understand it, and agree to be bound by it, and that my signed name below constitutes my legal digital signature.

WAIVER, RELEASE, AND INDEMNIFICATION AGREEMENT FOR STUDENT MINISTRY EVENTS AND OTHER CHURCH RELATED ACTIVITIES
SINGLE EVENT WAIVER
This Waiver, Release, and Indemnification Agreement (the “Agreement”) is entered into as of the date signed below by the undersigned parent(s) or legal guardian(s) (“Parent/Guardian”) of the minor participant (the “Participant”) for the benefit of Christ Fellowship (the “Church”), its affiliates, officers, employees, agents, volunteers, representatives, and assigns (collectively, the “Released Parties”).
By signing this Agreement, the Parent/Guardian consents to the Participant’s participation in the Church’s student ministry activity listed below for the duration of the event, and agrees to the terms and conditions set forth herein.
I. SCOPE
This Agreement applies to the Church-sponsored activity listed below. The activity may include but is not limited to: overnight camps, retreats, recreational programs, mission trips, transportation to and from events whether provided by the Church or by individuals, and all other activities organized for the purposes of student engagement and growth whether held on church property or off church property.
This Agreement shall remain in effect for the duration of the event listed below. A new Agreement must be signed to participate in other events hosted by the Church.
II. ACKNOWLEDGEMENT AND ASSUMPTION OF RISK
The Parent/Guardian acknowledges and understand that participation in the listed activity involve inherent risks, including but not limited to: physical injuries, illness, accidents during recreational or overnight stays, transportation-related risks, unforeseen conditions on property or at facilities where the activity is being held, emotional risks, risks of medical complications, and other emergencies.
The Parent/Guardian acknowledges that while the Church will make reasonable efforts to provide a safe environment, some risks are unavoidable. By signing this Agreement, the Parent/Guardian voluntarily assumes all such risks on behalf of the participant and agrees that participation is entirely voluntary.
III. RELEASE, WAIVER OF LIABILITY, AND INDEMNIFICATION
The Parent/Guardian, on behalf of the participant and themselves, fully release and discharge the Released Parties from any and all liability, claims, demands, caused of action, damages, and expenses (including attorney’s fees) arising from or relating to participation in the activity. This release includes, but is not limited to: injuries, property damage, loss sustained during the activity, emotional stressors in relation to participation, and incidental or consequential damages resulting from participation.
The Parent/Guardian agrees to defend, indemnify, and hold harmless the Released Parties from any claims, causes of action, liabilities, or costs arising from: special, incidental or consequential damages, injury or loss caused by participant’s participation in the activity to others, parent/guardian’s breach of representations or obligations under this Agreement, and claims made by participant or their estate against the Released Parties.
IV. MEDICAL CONSENT AND EMERGENCIES
The Parent/Guardian hereby consents to the provision of first aid or emergency medical treatment for the participant in the event of illness or injury during the activity.
In the event of an emergency and when the parent/guardian cannot be contacted, the undersigned Parent/Guardian authorizes a representative of the Church to consent to medical care for the Participant. The Parent/Guardian authorizes Church representatives to act as the Participant’s “personal representative” and to be treated as the Parent/Guardian would for all purposes of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and shall (1) have access to all of the Participant’s “individually identifiable health information,” including any “protected health information,” (2) possess, without limitation, the Parent/Guardian’s right of access to inspect and obtain a copy of protected health information about the Participant and (3) possess, without limitation, the Parent/Guardian’s right to an accounting of disclosures of protected health information. This authority hereby granted applies to any information governed by HIPAA. This grant of authority is limited to the time until the Parent/Guardian can be contacted, at which point the Church representative shall cease to be the Participant’s personal representative.
It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required, but it is given to provide authority and power on the part of the supervisor/church representative in the exercise of best judgment for the Participant’s care, upon advice by physician or other medical professional.
The Church does not assume financial responsibility for medical treatment or related costs. The Parent/Guardian is encouraged to ensure the Participant is covered by adequate health insurance. If covered by health insurance, the Parent/Guardian agrees to provide insurance card and information in advance, should it ever be needed.

V. PARTICIPANT CONDUCT
The Parent/Guardian acknowledges that the Participant is required to adhere to all rules, regulations, and codes of behavior set forth by the Church. These rules are, but not limited to: respect for other participants, staff, and property, compliance with safety instructions and guidelines, and prohibition of unsafe or inappropriate behavior.
Any violation of such rules may result in disciplinary action, including removal from the activity at the discretion of the Church.
VI. PHOTOS, VIDEOS, MOTION PICTURES, AND RECORDINGS
The Parent/Guardian grants full permission to the Church to use any photos, videos, motion pictures, recordings, and any other records or documents of the activity. No notice is required to be given to the Parent/Guardian and the Parent/Guardian will not be compensated for use of the photo for any purpose.
VII. COST AND EXPENSES
The Parent/Guardian assumes full responsibility for payment of the published and announced cost of the activity and agrees to pay that specified amount or any outstanding balance upon request by the Church. The Parent/Guardian assumes responsibility for any additional costs and expenses incurred by the Participant during the activity, including but not limited to: costs associated with medical care and other emergencies.
VIII. GOVERNING LAW
This Agreement shall be governed by and constructed in accordance with the laws of the State of Tennessee. Any dispute arising from or related to this Agreement or the activity shall be exclusively handled by the courts located in Tennessee.
IX. ACKNOWLEDGEMENT AND SIGNATURE
By signing below, the undersigned certifies that they are a parent/guardian of the Participant. The undersigned acknowledges that they have carefully read, understand this Agreement, and agree to its terms and conditions voluntarily and without reservation. The undersigned attest that the Participant is physically and mentally capable of participating in the activity outlined in this Agreement.

Signature(Required)

Consent for Adult – CF Waiver(Required)

WAIVER, RELEASE, AND INDEMNIFICATION AGREEMENT FOR MINISTRY EVENTS

AND OTHER CHURCH RELATED ACTIVITIES

SINGLE EVENT WAIVER

This Waiver, Release, and Indemnification Agreement (the “Agreement”) is a legally
binding agreement. Please read carefully before signing. Your participation in the
Church’s programs and activities is conditioned upon acceptance of the terms and
conditions of this Agreement. By signing below, you acknowledge that you have read
this Agreement, understood, and agreed to the terms and conditions of the Agreement.

I. PARTIES
This Agreement is entered into between Christ Fellowship Church (the “Church”),
including its officers, directors, employees, volunteers, agents, sponsors, affiliates, and
all persons or entities acting on its behalf (collectively, the “Released Parties”) and an
individual of or over the age of eighteen (18), or the parent(s)/guardian(s) on the behalf
of a minor (collectively, the “undersigned’)

II. SCOPE
For the purposes of this agreement, the activities covered include all Church-sponsored
events, outreach programs, overnight camps, retreats and associated activities
(collectively, the “Activities”).
The Agreement applies to participation in any and all Activities organized by the Church
whether conducted on Church property or at an offsite location. Activities may include
but are not limited to: overnight camps, retreats, recreational programs, mission trips,
transportation to and from events whether provided by the Church or by individuals, and
all other activities organized for the purposes of engagement, outreach and growth
whether held on church property or off church property.
This Agreement shall remain in effect for the duration of the below listed event for
which this Agreement is signed. A new Agreement must be signed for participation in
other, separate Activities hosted by the Church.

III. ACKNOWLEDGEMENT AND ASSUMPTION OF RISK
The undersigned acknowledges and understands that participation in the Activities
involve inherent risks, including but not limited to: physical injuries, illness, accidents
during recreational or overnight stays, transportation-related risks, unforeseen
conditions on property or at facilities where activities are being held, emotional risks,
risks of medical complications, and other emergencies.
The undersigned acknowledges that while the Church will make reasonable efforts to
provide a safe environment, some risks are unavoidable. By signing this Agreement, the
undersigned voluntarily assumes all such risks and agrees that participation is entirely
voluntary.

I. RELEASE, WAIVER OF LIABILITY, AND INDEMNIFICATION
The undersigned fully release and discharge the Released Parties from any and all
liability, claims, demands, caused of action, damages, and expenses (including
attorney’s fees) arising from or relating to participation in the activities. This release
includes, but is not limited to: injuries, property damage, loss sustained during activities,
emotional stressors in relation to participation, and incidental or consequential damages
resulting from participation.
The undersigned agrees to defend, indemnify, and hold harmless the Released Parties
from any claims, causes of action, liabilities, or costs arising from: special, incidental or
consequential damages, injury or loss caused by undersigned’s participation in the
activities to others, breach of representations or obligations under this Agreement, and
claims made by the undersigned or their estate against the Released Parties.

I. MEDICAL CONSENT AND EMERGENCIES
The undersigned hereby consents to the provision of first aid or emergency medical
treatment in the event of illness or injury during the activities.
In the event of an emergency which render the undersigned unable to make medical
decisions and when the emergency contact cannot be contacted, the undersigned
authorizes a representative of the Church to consent to medical care on their behalf.
The undersigned authorizes Church representatives to act as the their “personal
representative” and to be treated as the emergency contact would for all purposes of
the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and shall (1)
have access to all of the undersigned’s “individually identifiable health information,”
including any “protected health information,” (2) possess, without limitation, the right of
access to inspect and obtain a copy of protected health information about the
undersigned and (3) possess, without limitation, the right to an accounting of
disclosures of protected health information. This authority hereby granted applies to any
information governed by HIPAA. This grant of authority is limited to the time until the
undersigned is able to make medical decisions independently or the emergency contact
can be contacted, at which point the Church representative shall cease to be the
undersigned’s personal representative.
It is understood that this authorization is given in advance of any special diagnosis,
treatment, or hospital care being required, but it is given to provide authority and power
on the part of the supervisor/church representative in the exercise of best judgment for
the undersigned’s care, upon advice by physician or other medical professional.
The Church does not assume financial responsibility for medical treatment or related
costs. The undersigned is encouraged to ensure access to adequate health insurance.
If covered by health insurance, the undersigned agrees to provide insurance card and
information in advance, should it ever be needed.
I. PARTICIPANT CONDUCT

The undersigned acknowledges that they are required to adhere to all rules, regulations,
and codes of behavior set forth by the Church. These rules are, but not limited to:
respect for other participants, staff, and property, compliance with safety instructions
and guidelines, and prohibition of unsafe or inappropriate behavior.
Any violation of such rules may result in disciplinary action, including removal from the
Activity at the discretion of the Church.

II. PHOTOS, VIDEOS, MOTION PICTURES, AND RECORDINGS
The undersigned grants full permission to the Church to use any photos, videos, motion
pictures, recordings, and any other records or documents of the Activities. No notice is
required to be given and the undersigned will not be compensated for use of the photo
for any purpose.

III. COST AND EXPENSES
The undersigned assumes full responsibility for payment of the published and
announced cost of the Activities and agrees to pay that specified amount or any
outstanding balance upon request by the Church. The undersigned assumes
responsibility for any additional costs and expenses incurred during the Activities,
including but not limited to: costs associated with medical care and other emergencies.
IV. GOVERNING LAW
This Agreement shall be governed by and constructed in accordance with the laws of
the State of Tennessee. Any dispute arising from or related to this Agreement or the
Activities shall be exclusively handled by the courts located in Tennessee.

V. ACKNOWLEDGEMENT AND SIGNATURE
By signing below, the undersigned certifies that they are the individual to participate in
the Activities or they are a parent/guardian of the participant. The undersigned
acknowledges that they have carefully read, understand this Agreement, and agree to
its terms and conditions voluntarily and without reservation. The undersigned attest that
the participant is physically and mentally capable of participating in the Activities
outlined in this Agreement.

Signature(Required)

Model Love Volunteer Form- Providence Medical Clinic

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