The Well Church Youth Ministry 2018-2019

Universal Permission Form

Effective Dates: June 1, 2018 – May 31, 2019

Youth Information

Name _____________________________ Grade _________ DOB __________ Male/Female

Nickname______________________________ School: _______________________________

Primary Address:_______________________________________________________________

Secondary Address: _____________________________________________________________

Youth Email __________________________________________________________________

Youth Home Phone ________________________ Youth Cell Phone _____________________

Parent/ Guardian Information

Name(s) ______________________________________________________________________

Email(s) ______________________________________________________________________

List all phone numbers where the parent/guardian can be reached (type: i.e. home, cell)

Name__________________________ #_______________________ Type? _________

Name__________________________ #_______________________ Type? _________

Name__________________________ #_______________________ Type? _________

Name__________________________ #_______________________ Type? _________

Emergency Contact

Name_________________________ #_______________________ Relation? _____________

Name_________________________ #_______________________ Relation? _____________

Parental Consent

The undersigned does hereby give permission for my child ____________________________ (child’s name)(“Participant”), to attend and participate in any of The Well’s youth ministry activities, events, retreats and programs during the period of July 1, 2018 – June 30, 2019.

LIABILITY RELEASE: In consideration of The Well Church allowing the Participant to participate in youth ministry (Sunday worship, Sunday meeting, Activities, Events, Retreats, Trips), I, the undersigned, do hereby release, forever discharge and agree to hold harmless The Well Church, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the youth activities. I the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in youth ministry activities, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify The Well Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

EARLY RETURN HOME POLICY: Should it be necessary for my youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by The Well Church. My youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

_______________________________________ X___________________________________ ____________

Name of parent/guardian	Signature of parent/guardian Date

MEDICAL INFORMATION

YOUTH INFORMATION (Please Print)

Youth Full Name _____________________________________________ Nickname _______________ Home Address _______________________________________________________________________ Home Phone ________________________________________ DOB ___________________________

Parent/Guardian Contact Information

Parent/Guardian Name(s): _____________________________________________________________

List all parent/guardian contact phone numbers in best order to be reached: _____________________

___________________________________________________________________________________

NON-PARENT/GUARDIAN EMERGENCY CONTACTS

Name: _____________________________________ Relation:________________________________

Phone(s):___________________________________________________________________________

PRIMARY CARE PHYSICIAN

Name:_____________________________________________________________________________

Phone(s)_____________________________________ Fax: _________________________________

Name of practice: ____________________________________________________________________

INSURANCE INFORMATION

Medical Insurance Company: ____________________________ Phone: ______________________ Policy/Group ID#: _________________________________________________________________ Policy Holder’s Name (please print): ____________________________________________________

Required: Attach a copy of medical insurance card here.

MEDICATION:

List all medications the youth will take during any youth ministry trips, retreats, or events. This includes any prescription, non-prescription medications, herbal supplements and vitamins. Any participant under the age of 18 is required to give ALL MEDICATIONS to the adult youth leader in their original containers with complete dispensing instructions before the start of the event. Youth are not permitted to carry any prescription or non-prescription medication and will be sent home at the parent/guardian’s expense if they do.

Medication Name	Dose	Treatment for	Dispensing instructions

Example: Zyrtec	5mg	Seasonal allergies	Take one pill daily in the morning with food ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Over-the-Counter Medication Permission: Do you give permission for your youth to be given over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth ministry event?

No. Contact me or get medical help if my child has any minor medical concerns.

Parent signature_________________________________________________________________

Yes. I give permission for an adult youth leader to give my child approved over-the-counter medications as directed on an as needed basis to treat non-emergency medical conditions.

Parent Signature________________________________________________________________

MEDICAL CONDITIONS: Please answer in detail if applicable or write N/A. Attach additional pages if necessary.

List any medical conditions you have (asthma, diabetes, epilepsy, etc.):

List any allergies (drug/medicine, food, and/or environmental) and the severity and type of reaction:

Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know.

The Well Youth Ministry

Covenant of Community Expectations

The following rules and guidelines are equally binding on adult leaders/chaperones and youth.

Non-Negotiable Rules

Any participant failing to abide by these rules will be sent home immediately at personal/family expense.

• No use of illicit drugs or alcohol

• Presence at and full participation in all group activities, including adherence to curfews and other time-related instructions

• No sexual misconduct (defined as exposure, touching, or inappropriate reference to body areas normally covered by undergarments)

• Must be in assigned rooms by designated time

• Coed visitation only in assigned community room

• Smoking and the use of tobacco products are not allowed to, from, or during any trip.

• Will not break any American laws in the United States or any other country.

Guidelines for Living in Christian Community

• Adults and youth will be equally responsible for performing assigned tasks in a timely and cooperative manner.

• Participants will be respectful, encouraging, and will maintain a positive attitude toward others at all times, recognizing Christ’s presence in each other.

• Participants will be respectful of both common living spaces and the property of others.

• Participants will avoid the use of foul language, cursing, or any speech (including “humor”), which puts down, makes fun of, or stereotypes other persons or groups.

• Sleeping areas for males and females will be separate.

Youth Participant’s Statement: By signing this form, I pledge to honor God and respect others during this activity by following the rules and guidelines printed above. I understand that I cannot participate in the activity unless this completed form is on file.

x_________________________________________________________________________

Youth Participant’s Signature	Date

Parent/Guardian’s Statement: By signing this form, I agree to support the Covenant of Community Expectations printed above, and will accept responsibility for the payment of my child’s return transportation should s/he break one of the non-negotiable rules.

x_____________________________________________________________________________

Parent/Guardian’s Signature	Date

The Well Church Photo Release Form for Youth

I agree that The Well Church may photograph and record my child/dependent’s likeness and activities (Images) during church-related activities. I grant the following rights to The Well Church: permission to use and re-use, publish and re-publish, and modify or alter the Image(s) taken during the shoot. Use of the Images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the church website and on the Internet, and worldwide in perpetuity for the purposes stated above.

I waive my right to inspect or approve any editorial text or copy that is used in connection with the Images and release and discharge The Well Church from any and all claims arising out of use of the Images for the purposes described above, including any claims for libel, invasion of privacy, or other tortuous act.

I have read the foregoing. I fully understand its contents, understand that this agreement does not expire, and confirm my agreement by signing below. I am over the age of 21 and have legal capacity to sign the release.

Youth’s Name (print)	Parent/Guardian Name (print)
x Parent/Guardian Signature	Date

Image means all photographs, film, or other recordings taken of you as part of the Shoot.