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Mcfarlin united methodist church
Sr. High Weekend Mission Trip to Palacios, TX
Name: __________________________________________ Birth date: ___________________
Address & zip:_____________________________________________________________________
Home Phone: ______________________ Youth Email Address: __________________________
Youth Cell: ______________________ Text Okay?: Y N Cell phone provider: _______________
School: _________________________ Grade: _____ Sex: _____ Long Sleeve Shirt Size:_____
If you’re a visitor, who invited you? ___________________________________________________
Mother’s Name: ___________________________
Work #: ____________Cell #: ____________ Work #: _______________Cell #: _____________
Father’s Email Address: __________________________________________________
Mother’s Email Address: __________________________________________________
Emergency Contact and phone number (other than parents): ______________________________________________________________________________ Check here if any of the above information has changed since September 1, 2013
Check here if your child has a Current Notarized Medical Release form on file.
Parent Signature: ________________________________________________________________ Please make checks payable to “Bethany UMC” and put the event name in the memo field. Payment or payment
arrangements must accompany this form for registration to be complete. Refunds are for emergencies only and
exclude a $20 processing fee.
Check #____________ Cash $________ Youth Account $ _________ We don’t want anyone to not participate due to lack of funds. If you would like to donate funds to help others
attend, please write your donation amount here: $ _____
Yes! I can attend this event!! My car seats ____ passengers.
Bethany United Methodist Church Student Ministries
10010 Anderson Mill Road, Austin, TX 78750
Teresa Kingsbury, Director Student Ministries ext. 235
Maggie Todd, Student Ministries Administrator, ext. 228
Thomas Johnson, Student Ministries Middle School Programming Coordinator, ext 271
Todd Jones, Student Ministries High School Programming Coordinator, ext 274
Chris Sloan & Kayte Forester, Student Ministries Interns
As Needed Medicine Only:
My youth may be given the following medications according to recommended dosage on package as
needed under the supervision of Student Ministries Staff (please mark all that apply): ____ Tylenol
Parent signature: ________________________________
Salt and Light
Senior High Weekend Mission Trip
November 22-24, 2013
The First United Methodist Church of Palacios
will be our hosts along with long time Bethany United Methodist Church members Carl and Marty Rieck.
All BUMC Senior High Youth and their friends
Friday, November 22 – Sunday, November 24
Meet at BUMC Lighthouse Assembly Room at 5:00pm Friday (don’t forget to bring a sack supper with a drink). We will return at church at 4:00pm.
▪ Subject to tropical storms & hurricanes
What types of work will we be doing?
• Work at Martha’s Table where anyone who needs a hot meal can find one
• Exterior or interior painting
• Caring & Sharing Food Pantry
Where will be staying
: Texas Baptist Encampment in Palacios-
Todd Jones cell (956) 650-8581(emergencies only please)
Texas Baptist Encampment (361) 972-2717
Contact Todd Jones at 258-6017 x274 o Parent Participation:
Parents are always welcome and encouraged to participate. If you would like
to help with this event please contact Thomas Johnson.
Bethany United Methodist, First United Methodist of Palacios
Volunteer Consent, Liability Waiver/Release
Salt & Light, Senior High Weekend Mission Trip, Nov. 22-24, 2013 Project Location:
City of Palacios and surrounding rural areas Consent, Liability Waiver and Release:
The undersigned Volunteer (or undersigned Parent/Guardian in the case of a Volunteer under
the age of eighteen years) does hereby agree to indemnify and hold harmless Bethany United
Methodist Church and First United Methodist of Palacios
their volunteers, officers, agents,
and employees, from any and all claims or causes of action that may arise out of performance of
the undersigned Volunteer’s assigned duties with respect to the project at the Project Location.
The undersigned waive (s) and relinquishes any right of action against Bethany United
Methodist Church and First United Methodist Church of Palacios,
officers, agents, and employees, in connection with the Volunteer’s participation in the project
at the Project Location.
The undersigned waive (s) and relinquishes any right of action against the homeowners or other
charitable organizations for whom they are volunteering services.
The undersigned Volunteer (or Parent/Guardian) further authorizes the Volunteer’s image or
likeness of his/her image to be utilized in photography, videography, and promotional materials
related to this event.
If Volunteer is under the age of 18 years, the undersigned Parent/Guardian hereby consents to
the Volunteer’s participation in the Salt & Light mission trip at the project locations.
Volunteer Name (printed) ____________________________ E:Mail ______________
Address (printed) ___________________________________ Phone ______________
Over 18 years of age: Yes or No If No, Parent/Guardian must sign for Volunteer.
Parent/Guardian Name (printed): ___________________________________________
___________________________________ Dated: _____________________, 2013 Signature of Volunteer or Parent/Guardian
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