—APPLICATION—

Official use only:
Presbytery of Detroit Katrina Relief Trip 12
New Orleans, LA, April 9-17, 2011
_________________________________
_
—APPLICATION—
APPLICANTS MUST BE AT LEAST 16 YEARS OLD BY DEPARTURE DATE & HAVE HEALTH INSURANCE COVERAGE (See page 2 of 2)
A parent must accompany participants less than 18 years old.
HOW TO BOOK YOUR TRIP
1. Contact Us: Ask questions and check availability with trip coordinator Julie Smith at (248) 821-8216, or mfan81@yahoo.com.
2. Cost: $185 per person which includes PDA fees, in camp meals and in transit lodging. The application and $185 fee are due
Sunday, March 20, 2011 (the Orientation Meeting date) and the fee is non-refundable thereafter.
3. Application: Mail completed application with a check payable to the Presbytery of Detroit for the full payment of $185 to:
Katrina 12 Trip, c/o Julie Smith, 99 Wayne St., Pontiac, MI 48342 (mfan81@yahoo.com, 248-821-8216). You will receive an email
confirmation of your registration when the application and check are received.
4. Orientation Meeting: Sunday, March 20, 4:00 PM, at First Presbyterian Church, 99 Wayne St., Pontiac, MI 48342
5. Travel: Participants will carpool in personal vehicles from the Detroit area & are responsible for fuel and in-route meal expenses.
Name: Last________________________________ First ________________________ Preferred/Nick ________________________
Address_____________________________________ City/State/Zip_______________________________________ Gender ______
E-Mail Address (Important):__________________________________________________________ Birthdate _________________
Phone: Home__________________________ Work__________________________ Cell ___________________________________
I allow my photograph & name to be used on our website to chronicle our mission trip. YES  is assumed unless you check NO 
Leading Devotions ,
Check areas of interest:
Journaling ,
Reporting ,
Photography ,
Blog Publishing .
Check communications equipment you will bring: Digital Still  or Video Camera  with USB cable, Wireless-Enabled Computer
Do you want to work in New Orleans, LA  or Pearlington, MS  ? If neither is checked you will work in New Orleans.
TRAVEL & HOTEL ARRANGEMENTS
Are you driving: YES or NO? If yes, provide the make and model of your vehicle: __________________________________
How many people can you take (including yourself) with luggage? _______________________
Make motel reservations for me on the way South to LA (Check: YES  or NO ) and North to MI (Check: YES  or NO )
Rooms are double occupancy. Name your preference for a roommate: _________________________________________________
SKILLS ASSESSMENT
Show skill level using these numbers in boxes below: 1-Willing to try; 2-Can do with guidance; 3-Do well
First Aid/CPR Skills
Cook
Pastor, YES or NO
Landscaping
Roofing
Priming/Painting
Masonry/Brick, Plaster
Tile: ceramic, etc.
Flooring, vinyl, etc.
Flooring: Laminates
Cabinet Installation
Door Installation
Window Installation
Siding
Drywall Finishing
Drywall Hanging
Insulation
HVAC
Plumbing
Electrical
Finish Carpentry
Framing Carpentry
Remove drywall/floors
Foundation
Lead work crew, Y / N
independently; 4-Do well and guide others; 5-Work in trade.
I am comfortable on a (check all that apply): Ladder , Roof , Raised Deck 
Other skills and abilities: ______________________________________________________________________________________
Any work limitations (things you must avoid)?: ____________________________________________________________________
Page 1 of 2
Presbytery of Detroit Katrina Relief Trip 12
New Orleans, LA, April 9-17, 2011
Official use only:
_________________________________
_
SUPPLEMENTAL MEDICAL INFORMATION
PURPOSE: This form is kept by the camp nurse. Its sole purpose is to alert the Trip Leader and medical providers to any
condition that might assist in your care in an emergency medical situation. All information on this form will be kept
confidential and the form will be kept on file at the presbytery offices at the conclusion of the trip.
Participant name: ____________________________________________________ DOB_________________________
Church /Organization Name__________________________________________ Phone__________________________
Church /Organization Address ________________________________________________________________________
Please describe any dietary restrictions_________________________________________________________________
_________________________________________________________________________________________________
Do you have any physical conditions that could be a health/safety factor at any time during this trip? (Check) NO  or YES
If yes, please describe: ___________________________________________________________________________________
______________________________________________________________________________________________________
Please list prescription medications for any condition described above: ____________________________________________
______________________________________________________________________________________________________
Medical Insurance Provider __________________________________Policy #__________________________________
Address ______________________________________________________________________________________________
Phone Number_________________________ Name of primary insurance holder: __________________________________
**BRING YOUR MEDICAL INSURANCE CARD WITH YOU**
***Medical insurance is available for the mission trip, through the Presbytery. Please check the box if you do not have health
insurance of your own and need the Presbytery to provide it for you. 
Participant Signature_________________________________________________ Date______________________________
The next three pages are separate forms required by PDA. Unfortunately, there is some duplication of information but
it is important to complete these forms in entirety.
Page 2 of 2
Presbytery of Detroit Katrina Relief Trip 12
New Orleans, LA, April 9-17, 2011
Official use only:
_________________________________
_
Volunteer Information and Release form
Thank you for volunteering with Presbyterian Volunteer Villages. Teams like yours are making a difference across the
country as you share the love of Christ by giving of your time and service to help families clean up and rebuild.
Please complete the following information. This provides PDA with a record of your volunteer work and allows us to
send you 1) a letter or certificate acknowledging your volunteer service and 2) Mission Mosaic, a semi-annual update (in
magazine format) of how Presbyterians are responding to disasters around the world. This form also includes required
release information and must be completed before your participation in the village begins.
Please legibly PRINT the following information:
Check one:
Mr.
Mrs.
Ms.
Rev.
Other ____________
Name (first and last) ____________________________________________________________
Email address __________________________________________________________________
Would you like to receive PDA Rapid Information Network (PDA-RIN) email updates on disaster responses? We
encourage you to share the information with your congregation. Yes
No
Phone numbers (please specify if home/office/cell) _____________________________________________
Mary Lloyd, Presbytery Contact
Who is your Team Leader on this volunteer mission ____Julie Smith, Mission Team Leader____
(person who organized the trip and contacted PDA)
What group are you volunteering with? (the church, presbytery, or organization your team is part of)
Organization Name ______Hands-On Mission Work Group, Presbytery of Detroit_____________
City/State/Zip ____17575 Hubbell, Detroit, MI. 48235__________________________________
Team Leaders please also include:
Organization Street Address __17575 Hubbell; Detroit, MI. 48235___________________
Organization Phone# ________313-247-0792____________________________________
Which village are you assigned to ______Olive Tree_________________________
Arrival Date in the village __April 10, 2011_______ Departure Date ___April 16, 2011__________
Have you been to a Presbyterian Volunteer Village before? If yes, when and where?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Please continue to the next page for required release information and signatures.
PDA General Release and Volunteer Information Form - 07/09
Page 1 of 3
Presbytery of Detroit Katrina Relief Trip 12
New Orleans, LA, April 9-17, 2011
Official use only:
_________________________________
_
GENERAL RELEASE, INDEMNIFICATION AGREEMENT AND
AUTHORIZATION FOR MEDICAL TREATMENT
Participant name: _________________________________________________(“Participant”)
DOB: __________________________________
Home Address: ______________________________________________________________________
City/State/Zip: ______________________________________________________________________
Telephone: (Cell) __________________________ (Day/Evening)______________________________
E-mail address _____________________________________________________________
In consideration of the opportunity provided to me to participate in the PDA Disaster Response
and any services, housing, food, and the like provided by PCUSA (as defined below), I,
Participant, hereby understand and agree that the Presbyterian Church (U.S.A.) General
Assembly, all synods, presbyteries, and local churches and their corporations and related
entities, their staff, volunteers, directors, officers, agents, elders, deacons, representatives,
successors, assigns and entities (hereinafter collectively referred to as "PCUSA") will not be
responsible in any way whatsoever for loss, damage, or injury of any kind or in any manner
resulting from or in connection with my participation in PDA Disaster Response.
I, Participant, understand and agree that PCUSA does not and cannot guarantee my safety in
connection with the PDA Disaster Response. Further, I understand and agree the activities
involved with the PDA Disaster Response may include but are not limited to the following:
difficult living conditions, risks concerning means of travel, food, water, diseases, pests, poor
sanitation, and other health related situations, including potential injury while working. I accept
and assume all responsibility for all risks which may occur during, in connection with, or result
from my participation in the PDA Disaster Response including, but not limited to, potential
injury while working.
RELEASE: With the above in mind and by my signature below, I fully understand, agree and
hereby voluntarily release and forever discharge PCUSA. PCUSA shall not be responsible or
liable in any way for any accident, loss, death, injury or damage to myself or my property, in
connection with my participation in the PDA Disaster Response or any portion of the PDA
Disaster Response even if said injury or action is due to the alleged negligence of PCUSA.
Further, I do hereby agree to indemnify and hold PCUSA harmless against any and all
liabilities, damages, claims, actions or rights of action, suits, judgments and associated costs and
expenses (including, without limitation, attorneys' fees) of whatsoever kind in connection with
my participation in the PDA Disaster Response or any portion of the PDA Disaster Response.
Further, I make this agreement on behalf of my heirs, agents, fiduciaries, successors and assigns.
I waive, knowingly and voluntarily, each and every claim or right of action I have now or may
have in the future against the PCUSA related to my participation in the PDA Disaster Response,
even if any such claim or right of action is caused by PCUSA's alleged negligence. This
document does not release PCUSA from gross negligence.
PDA General Release and Volunteer Information Form - 07/09
Page 2 of 3
Presbytery of Detroit Katrina Relief Trip 12
New Orleans, LA, April 9-17, 2011
Official use only:
_________________________________
_
MEDICAL COVERAGE: I understand and acknowledge that no medical or other insurance or health care
benefits will be provided to me by PCUSA during my participation in the PDA Disaster Response, and I certify
that I have sufficient health, accident and liability insurance or other benefits to cover any bodily injury or
property damage I may incur while participation in the PDA Disaster Response and to cover bodily injury or
property damage caused to a third party as a result of my participation in the PDA Disaster Response, as follows:
Company ________________________________________ Policy #__________________________________
Address ___________________________________________________________________________________
MEDICAL RELEASE: I hereby state that I am in good health and have all medications necessary to treat any
allergic or chronic conditions, and I am able to administer such medications without assistance. If at any time
during my participation in the PDA Disaster Response I need emergency medical care and am not able to give
consent because of my physical or mental condition, I authorize PCUSA to make emergency medical care
decisions on my behalf, and I specifically release PCUSA, in making those emergency medical care decisions,
from any and all liability associated with said decisions, even if injury or death is the result of PCUSA's alleged
negligence.
Person to be notified in case of injury:
Name _______________________________________________________________________
Telephone: _____________________________ (evening)______________________________(daytime)
Cell Phone: _________________________________________
ALL PARTICIPANTS MUST SIGN:
My signature below indicates that I have read this entire two page document, understand it completely,
and agree to be bound by its terms.
SIGNATURE OF PARTICIPANT: __________________________________________
DATE EXECUTED: ______________________________________________________
SIGNATURES MUST BE WITNESSED:
SIGNATURE OF WITNESS: _____________________________________________
DATE EXECUTED: _____________________________________________________
(SIGNATURE OF PARENT OR LEGAL GUARDIAN IS ALSO REQUIRED IF PARTICIPANT IS UNDER
18 YEARS OF AGE.)
SIGNATURE OF PARENT/LEGAL GUARDIAN (if applicable)_________________________
SIGNATURE OF WITNESS: _____________________________________________
DATE EXECUTED: _____________________________________________________
PDA General Release and Volunteer Information Form - 07/09
Page 3 of 3