Vacations That Give
Trip Application 2015-16
Location and Date of Trip for which you are applying
_________________
Name of Trip
__________________________________
Date of Trip
Name______________________________
Address_______________________________________________________
Street
City
State
Zip
Home Phone_______________________ Cell Phone__________________
Date of birth____________
email address________________________________
Do you have medical insurance? _____
Do you have health concerns of which we should be informed in case of accident or hospitalization?______ If yes, please
specify__________________________________________________________________________________________________
Do you have any special skills for the trip for which you are applying?_____
________________________________________________________________________________________________________
(specialized skills are not necessary, it’s just helpful for organizers to be aware for assigning jobs)
Would you allow us to use pictures of you on this trip on the Vacations That Give website?_______________________________
Signature___________________________________ Date____________________
(T-Shirt size _______________)
HOLD-HARMLESS AND RELEASE AGREEMENT
This agreement entered into on day ____ of ____________, 20__ is between volunteer participant
__________________________ and “Vacations That Give,” A Ministry of the Sisters of Saint Anne. This
agreement states that neither “Vacations That Give” nor the Sisters of Saint Anne will be held liable in case of
any injury incurred from usage of manual and/or power tools. This agreement states that the above mentioned
volunteer comes willingly to participate in “Vacations That Give” volunteer activities and work projects with prior
knowledge of the nature of its work and activities. The above mentioned volunteer/participant will hold harmless
and release from any and all claims or any liability: Sisters Yvette Dargy and Pauline Laurence, Director Regina
O’Connor, the Community of the Sisters of Saint Anne, and any/all employees from any and all injury or liability
that may occur while participating in this volunteer trip and activity or any liability or injury associated with the
repair work of an individuals’ home. The above mentioned volunteer also understands that “Vacations That
Give,” and the Sisters of Saint Anne do NOT provide medical insurance or coverage to its volunteer participants
during their volunteer work and that it is the above mentioned volunteer's responsibility for coverage should any
medical situation arise either during or after their volunteer activities.
This agreement is entered into by:
Participant’s Signature (over 18) ______________________________________
Date:___/___/___
Parent/Guardian Signature if under 18
Date:___/___/___
Name (print) __________________________
Permanent Address_____________________________ Town/State/Zip__________________________
Witnessed by:(please print)__________________________
Witness Signature:_________________________________
Date:___/____/____
VOLUNTEERS HEALTH INSURANCE / MEDICAL RELEASE FORM
PLEASE PRINT
______________________________________________
___/___/ ___
_______________
_________________ M
Name of Participant
Birth Date
Home Phone
Cell Phone
______________________________________________________________
_________________________
Home Address Street
Parish
Town
Zip
_______________________________ ______________________
Emergency Contact Person
(____)___________ (____)_______
Relationship to You
Day Phone
Evening Phone
_____________________________________________________
_____________________________
Complete Name of Insurance Company
Policy Number/Group Number
___________________________________
Employer’s Name
Name on Insurance Card
****Must Enclose a Copy of both sides of the Insurance Card****
Are there any limitations to the activities in which the volunteer can participate? Yes_____No_____
_________________________________________________________________________________________________
If yes, please explain
Is there anything about the volunteer’s health that we should be aware of such as:
_____Diabetes
_____Fainting Trouble
_____Epilepsy
_____Migraines
_____Bleeding Disorders
_____Asthma
_____Heart Problems
_____Severe Allergic Reactions (Bee Sting/Food/other) Will you have an Epi Pen? ____Yes
____No
_____Other health issues we should be made aware of____________________________________________________
If any of the above is checked, please submit a statement of how the person has been treated and with what medication(s)
_________________________________________________________________________________________________
Current Medications: (Name, Dosage, frequency and reason for medications)________________________________________
All medication must be in the original containers
Blood Type:______
If known
Date of TETANUS BOOSTER:___/___/___
Most Recent
Most recent physical exam:___/___/___
Should be within the last 12 mos.
Emotional/Psychological condition(s) and/or concerns:__________________________________________
F
Circle One