Dear Folks Interested in WISDOM's Interfaith Connect Global Youth Service Day in partnership with YouthVille Detroit on Sunday April 25th from 10:00 AM - 4:00 PM.
We are finally set for our interfaith community service event. We hope adults, young adults and teens of many faith traditions will come together on this Global Youth Service Day to assemble and paint park benches, paint picnic tables and the park fence, mulch, rake, weed and plant flowers, and have some time to make new friends.
Below are the flyers for the event at Gordon Park in Detroit along with registration forms, permission slips and waiver forms, health forms and a contract. Please note that all forms must be signed by parents in order for their son or daughter to participate in this interfaith event. Youth and parents must read, complete, sign and submit all forms.
I am asking that all forms be mailed by April 20th to the WISDOM Address at
WISDOM
P.O. Box 525
Bloomfield Hills, MI 48303
If you plan to bring these forms with you and your youth to the event, you must contact me and let me know this.
And all questions should be forwarded to me at
gailkatz@comcast.net or 248-978-6664
Please get back to me as soon as possible with an estimate of how many youth/young adults plan to come to Gordon Park from your organization, and how many adults will be accompanying them.
We are asking everyone to bring their own picnic lunch. Beverages will be supplied by YouthVille Detroit, and WISDOM will supply some goodies for dessert.
Boots, jeans, old clothes, insect repellent, sun screen and rain gear if needed should be brought by all participants.
Youthville Detroit will supply work gloves and tools.
I look forward to hearing from you.
Gail Katz
WISDOM President
JOIN INTERFAITH CONNECT!!
(Youth Division of Women's Interfaith Solutions for
Dialogue and Outreach in MetroDetroit)
In Partnership with Youthville Detroit
FOR AN INTERFAITH COMMUNITY SERVICE EVENT
FOR GLOBAL YOUTH SERVICE DAYS!
ADULTS, YOUNG ADULTS, AND TEENS
OF ALL FAITH TRADITIONS INVITED!
SUNDAY, APRIL 25, 2010
10:00 AM - 4:00 PM
(Come for all or part of the day!!)
At Gordon Park
Clairmont and Rosa Parks Blvd. in Detroit
(parking on either side of the park or in lot across the street)
At this Interfaith Community Service Event we will
- Assemble and paint park benches
- Paint picnic tables and park fence
- mulch, rake, weed and plant flowers
Bring a picnic lunch, boots, jeans, old clothes, insect repellent, sun screen, rain gear if necessary
Beverages, work gloves, and tools provided by Youthville Detroit!!
Do not bring any electronic devices!!
Please see attached registration forms, permission slips, waiver forms, health forms and contract. All forms must be signed by parents in order for their son/daughter to participate in this event! Youth and parents must read, complete, sign and submit the contract and health form to participate.
Training and Orientation for Adult facilitators along with 2-3 of their youth participants will be held on Monday, April 19th at Youthville Detroit, 7375 Woodward, Detroit 48202 at 6:00 PM
An Adult Must Accompany Each Group of Youth
(No More than 8 Youth Per Adult)
QUESTIONS? CONTACT Gail Katz 248-978-6664 or Nancy Otto 248-227-4159
_____________________________________________________________
Youth Director/Leader Registration Form
10:00 AM – REGISTRATION
10:15 AM - 1:00 PM Work Cleaning up Gordon Park in Detroit
• Assemble and paint park benches
• paint picnic tables
• mulch
• rake
• weed and plant flowers/plants
• paint the fence
1:00 PM - 2:00 PM "GETTING TO KNOW YOU LUNCH"
2:00 PM - 4:00 PM Continue working in Gordon Park
NAME OF CONTACT ______________________________________________
NAME OF ORGANIZATION _________________________________________
EMAIL ADDRESS ________________________________________________
CELL PHONE __________________ HOME/OFFICE PHONE ______________
FAITH TRADITION (optional) ______________________________________
How many people are in your group? ________________________________
What are the ages of the youth/young adults that are coming with you? ___
The participants from each organization/family must complete individual permission slips/liability waiver & release forms (See attached forms) to participate in this Interfaith Connect event. There is a separate form for adults and youth (18 and under).
These registration forms should be mailed to:
WISDOM, P.O. Box 525, Bloomfield Hills, MI 48303
by April 20th. If you are planning to bring the permission slips with you, please contact Gail Katz, WISDOM President and let her know this.
248-978-6664, gailkatz@comcast.net
NO youth can participate without a signed permission slip!
______________________________________________________________
ADULT
Liability Waiver & Release Form
Name of participant_______________________________________________________
Religious Institution/Faith Tradition_________________________________
Home phone ___________________________________________________
Cell Phone _____________________________________________________
E-mail ________________________________________________________
Liability Waiver and Release Form
On this 25th day of April, 2010, intending to be legally bound hereby, the undersigned agrees and does hereby release from liability and to indemnify and hold harmless WISDOM (Women’s Interfaith Solutions for Dialogue and Outreach in MetroDetroit) and YouthVille Detroit. This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for this event. The undersigned further agrees to abide by all the rules and regulations promulgated by WISDOM and Youthville Detroit.
________________________________________________________________
(Signature of participant)
________________________________________________________________
(Date) ( Phone numbers in case of any emergency)
ADULT
Liability Waiver & Release Form
Name of participant_______________________________________________________
Religious Institution/Faith Tradition_________________________________
Home phone ___________________________________________________
Cell Phone _____________________________________________________
E-mail ________________________________________________________
Liability Waiver and Release Form
On this 25th day of April, 2010, intending to be legally bound hereby, the undersigned agrees and does hereby release from liability and to indemnify and hold harmless WISDOM (Women’s Interfaith Solutions for Dialogue and Outreach in MetroDetroit) and YouthVille Detroit. This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for this event. The undersigned further agrees to abide by all the rules and regulations promulgated by WISDOM and Youthville Detroit.
________________________________________________________________
(Signature of participant)
________________________________________________________________
(Date) ( Phone numbers in case of any emergency)
______________________________________________________________
YOUTH (Under 18)
Liability Waiver & Release Form
Name of participant_____________________________________________________________
Advisor/Teacher/Parent Responsible _________________________________
Advisor/Teacher/Parent phone number _______________________________
Liability Waiver and Release Form
Your son/daughter is eligible to participate in the Interfaith Connect/YouthVille Detroit Global Youth Service Day event on this 25th day of April, 2010. This event will begin at 10:00 AM and end at 4:00 PM. This activity will take place under the guidance and the supervision of staff and volunteers from YouthVille Detroit. There is a safety training session on Monday, April 19th at 6:00 PM at YouthVille Detroit that youth leaders and the youth themselves should attend. Participants must wear protective wear (gloves, goggles, masks) as needed which will be more specifically defined at the training session and in the participant contract. Please do not bring electronic devices, i.e. IPODS, Handheld video games, Play stations, etc. Cell phones should be used only for emergencies during this event.
I hereby consent to participation by my son/daughter, _______________________________ in the event described above. I understand that this event will take place away from facility grounds and that my son/daughter will be under the supervision of the YouthVille staff and volunteers on April 25, 2010. I consent to the conditions stated herein of this form and the method of transportation to and from the site by the sponsors of their youth group. In consideration of my son/daughter being allowed to participate in this event, I hereby agree on behalf of myself and my child to release YouthVille Detroit and WISDOM, and any and all affiliated organizations, their employees, agents, and representatives, including volunteer drivers (collectively "Releasees"), from any and all claims including negligence, which may be asserted by me or my child, or on behalf of my child, arising from or relating to my child's participation in this event.
In the event this release form on behalf of my child is held to be invalid or unenforceable, I hereby agree to indemnify and hold harmless Releasees from any and all claims, including negligence, which may be asserted by me or my child or on behalf of my child arising from or relating to my child's participation in this event. The undersigned agrees and does hereby release from liability and to indemnify and hold harmless WISDOM (Women’s Interfaith Solutions for Dialogue and Outreach in MetroDetroit and YouthVille Detroit. This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for this event. The undersigned further agrees to abide by all the rules and regulations promulgated by WISDOM and the Youthville Detroit.
I give my permission for my child to participate in this community service project.
_____________________________________ ________________________
(Signature of parent/guardian) (Date)
(Parent/guardian’s home phone, cell phone, emergency contact)
______________________________ _______________________________
Parent’s e-mail Youth e-mail
______________________________________________________________
PARTICIPANT CONTRACT
Global Youth Service Day is an experience where you will have the opportunity to help revitalize the Detroit community, earn service hours, grow in leadership and enrich your life. Interfaith Connect is giving youth and young adults of many faith traditions the chance to interact with others that you may never have had the chance to meet and make new friends!!
The success of this event will depend on positive attitudes and the willingness to participate fully in the program with enthusiasm and cooperation. To help promote these goals the following are some guidelines that you are asked to read and commit to following during your participation.
GOALS
♦ To bring positive energy and hope to the community.
♦ To respect the rights and dignity of all those we meet and help.
♦ To develop leadership skills and provide an experience of working as a team.
♦ PROGRAM GUIDELINES
♦ Participants must submit a signed health release form with emergency contact numbers and insurance.
♦ Participants must stay on worksite grounds unless accompanied by an adult.
♦ Participants are not allowed in vehicles driven by anyone under the age of 21. No one is allowed to ride in the back of a pickup vehicle.
♦ No smoking by participants or adult volunteers.
♦ Dress should be appropriate for the weather and activities. Work shoes that cover the entire foot and are sturdy -- required. NO SANDALS! You must wear pants with a belt. No sweat pants or shorts. You should wear old clothes that you don't mind getting messy.
♦ Participants must use tools only as instructed.
♦ Absolutely no drug or alcohol use.
In order for the event to be as successful and positive for everybody, participants who cause a negative experience for others or the program through an unwillingness to follow the guidelines, disrespect to adult leaders, staff or other participants, or involvement in any drug or alcohol use will result in the participant being sent home.
I have read and agreed to the above program goals, guidelines and participant responsibilities and would like to be a participant in the Global Youth Service Day event.
Date: __________________ _____________________ Participant Signature
Date: ___________________________________________ Parent's Signature
___________________________________________________________
HEALTH FORM
And Medical Treatment Release Form
NAME __________________________________________
BIRTHDATE ________________ _________________________
ADDRESS ________________________________________________
CITY _____________________________ ZIP ______________________
HOME PHONE ______________________________________
ALTERNATE PHONE ___________________________________
PAGER/CELL/ OTHER ___________________________________________
EMERGENCY CONTACT: _______________________________________
PHONE: __________________________________________________
FAMILY PHYSICIAN: _____________________________________________
ADDRESS: _________________________________________
PHONE: __________________
HEALTH INSURANCE COMP: _______________________________________
POLICY # ___________________________________________________
Is there any special dietary or medical requirements: i.e. asthmatic, diabetic, hypoglycemic ?
Yes / No
If yes, please describe condition and specific needs.
______________________________________________________________________________
______________________________________________________________________________
Are there any restrictions or recommendations?
______________________________________________________________________________
______________________________________________________________________________
Please indicate if your son/daughter is on any kind of medication? (For what medical problem, what kind of medication, dosage, special instructions, i.e. with meals, etc. )
______________________________________________________________________________
______________________________________________________________________________
Does your son/daughter have any allergies? What are they and what are their symptoms? What treatment do they take for their allergies?
______________________________________________________________________________
______________________________________________________________________________
Is your son/daughter allergic to any medications or drugs? I.e. penicillin, antibiotics including antibiotic ointments? ______________________________________________________________________
Immunization history: please include dates
DPT Booster _________________ Tetanus _______________
Polio __________________
PAST ILLNESSES: (Check mark the ones that apply)
Asthma _____ Convulsions _____ Heart Trouble _____ Rheumatic Fever ____
Diabetes _____ Bronchitis _____ Kidney Trouble _____ Sinusitis _____
Hay Fever _____ Fainting _____ Allergy to Bee Sting _____
Allergy to Poison Ivy ______
Medical Treatment Release
As a parent/guardian, I do hereby authorize the treatment by a qualified and licensed Medical physician, selected by the YouthVille staff, in an emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed, to hospitalize, secure proper treatment for and to authorize injection, anesthesia or surgery for my son /daughter ____________________. This authority is granted only after a reasonable effort has been made to reach me.
In signing this application, I hereby certify that the above information is correct and give permission for my son/daughter to be transported to and from a medical facility in the case of a medical emergency, and for the release of medical records to an attending physician in case of illness.
In case of medical emergency, I understand that every effort will be made to contact parents or guardians of participants. In the event that I cannot be reached, I hereby give permission to the physician selected by the YouthVille staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my son/daughter, as named herein.
In addition, I understand that no medication for pain relief such as Tylenol, Advil or aspirin will be dispensed by the staff unless in a medical emergency situation. Accordingly, I hereby give my son/daughter permission to take __________________ (list type of pain reliever you will be sending with your son/daughter) according to the prescribed recommended dosage of the pain reliever as needed.
Name of minor: ____________________________
Relationship to you: _________________________
This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.
Signature of Parent or Guardian ___________________________________
Date: _________________________________________________________
Print name of Parent or Guardian ___________________________________
