Plugged In March 16th – 18th RELEASE FORM TO

plugged in march 16th – 18th release form to: parents or guardians re: emergency medical treatment please print clearly & co

Plugged In
March 16th – 18th
RELEASE FORM
TO: Parents or Guardians
RE: Emergency Medical Treatment
PLEASE PRINT CLEARLY & COMPLETE THE ENTIRE FORM BELOW!
(Don’t forget to read & agree to the guidelines on the second page &
return the completed form)
Name of student:
________________________________________________________________________
Date of Birth: ____________________
Address:
_______________________________________________________________________
City: _________________ State: ______ Zip: _______
Grade: _______ Graduation Year: _______ School: _______
EMERGENCY CONTACT INFORMATION
Parent’s Home Phone:
__________________________________________________________________
Parent’s Work Phone:
__________________________________________________________________
Parent’s Cell Phone:
__________________________________________________________________
Parent’s Email:
__________________________________________________________________
In case of emergency notify:
__________________________________________________________________
Phone 1: __________________________ Phone 2:
__________________________
HEALTH INSURANCE INFORMATION
Insurance Company:
__________________________________________________________________
Claims Mailed to:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Policy or I.D. Number: _________________________________
Insurance Company Phone: _________________________________
Family Physician: _________________________________
Family Physician Phone: _________________________________
Medications currently taking: (list all, even vitamins)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Last tetanus shot: ____________________ Blood Type: _________
List all allergies:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Is student allergic to Latex or any Medications? __________
Has the student been diagnosed with Asthma or Diabetes? __________
Has the student been prescribed an Eppy Pin?
__________________________
*(We expect the student to always have the pin available)
Does the student have any food allergies? __________
(if so please attach a detailed description of all allergies to this
sheet)
Parental Permission to give: (please circle) Advil Tylenol Aspirin
Pepcid Benadryl
Other__________________________________
Special instructions regarding student:
__________________________________________________________________________________________
__________________________________________________________________________________________
ASSUMPTION OF RISKS
IN CONSIDERATION of the Church allowing me or my child to participate
in events, activities, or travel with the Church and all related
activities associated with the Church, including participation in the
Youth Group, and all activities related to the Youth Group. I
acknowledge that I am aware o the possible RISKS, DANGERS AND HAZARDS
associated with participation in the Activities including the possible
risk of severe or fatal injury to myself or others. These risks
include but are not limited to the following:
*risks associated with traveling to and from activities by means of
private and public transportation
*risks associated with failing to follow the instructions or
directions of the person in charge of the activities
*risks associated with the participation in the activities
*risks associated with medical problems arising before, during and
following participation in activities and other not mention probable
and unforeseen risks.
DISCLAIMER AND RELEASE OF LIABILITY
I, for myself or my child, voluntarily accept and fully assume such
risks, dangers and hazards and the possibility of personal injury,
death, partial or permanent disability, property damage or loss
resolution from me or my child’s participation in the activities. I
release, indemnify and hold harmless the Church, its trustees,
directors, corporation members, staff, agents, volunteers members and
representatives from: a) any loss, personal injury, accident,
misfortune or damage to the above named or his/her property, with the
understanding that reasonable precautions shall be taken to ensure the
health and safety of the above named; b)any claims, demands, actions
and costs for any loss, injury, damage or expense whatsoever that
might arise out of me or my child’s participation in the Activities;
and c) any and all liability for any damage to the personal property
of, or personal injury to, any third party resulting from me or my
child’s participation in the activities.
ACKNOWLEDGEMENT
(Insert Students Name) ____________________________may participate in
the Plugged In Community Event.
As a parent or guardian, I authorize an adult Counselor and/or Youth
Pastor to make legal decisions, medical
decisions, or otherwise, concerning said minor during the time of the
student ministry event. I also agree
that I will immediately notify the Student Ministry Office of First
Baptist Church, in writing, of any changes to the information above,
medical or otherwise. I hereby release First Baptist Church/Plugged In
and its sponsors of any legal responsibilities and liability in the
event of an accident or injury. As a parent or guardian I have
carefully and truthfully provided all the information requested and
give my permission for my child to participate in the Plugged In
Community event. I also give my consent for photos and videos produced
from this event that may include my student to be published/printed
for the purpose of event recaps and future event promotions.
Both my child and I have read and understand that she will be subject
to all the rules, regulations and policies outlined in the Student
Ministry Guidelines.
Parent/Guardian Signature: _____________________________________ date:
___/___/___
Student Signature: _____________________________________ date:
___/___/___
PLUGGED IN COMMUNITY EVENT GUIDELINES
These guidelines are here to protect the students and to provide the
best possible atmosphere for you to
enjoy our event and grow in Christ. By coming to this event you have
agreed to abide by each rule. If you willfully disobey the rules, you
forfeit any free time and/or the right to stay at the event.
Transportation home will be at the parent’s expense and attendance at
any future events will be pending.
IN GENERAL:
1. Be where you are supposed to be, when you are supposed to be there,
doing what you’re supposed to be doing… and “When in doubt, DON’T!”
SPECIFIC:
1. No phone or chargers
2. No driving your own car…keys will be turned in to your counselor
apron arrive to your host home
3. “In rooms’ and “lights out / stuff off” will be followed by
everyone according to the schedule
4. No tobacco, alcohol, drugs, fireworks, or weapons.
5. Clothing that promotes un-Christian values will not be permitted
6. No short shorts or “daisy dukes”
7. Profanity or bullying behavior will not be tolerated
8. Keep your rooms clean! Any Intentional destruction or abusive
treatment of property (accidental or intentional) will require full
replacement cost and immediate transportation home at parent’s expense
9. Everyone is expected to participate in all activities, sessions and
meals.
10. Be where you are supposed to be on time!
11. Respect all adult volunteers and each other. Counselors and/or
Chaperones have full authority, so respond immediately to their
requests, instructions and correction.
12. During all sessions we need to be quiet (when appropriate) to
avoid distracting those who want to grow in Christ (1 Thessalonians
5:10).
Each student who attends the Plugged In Community Event is expected to
conduct herself in a Christ-like manner at all times (1 John 2:6)