Permission toParticipate in Activities at St. Paul Lutheran Church 2010

Student Information

Name ____________________________________________   Age ______  Date of Birth __________

Address/City/Zip _____________________________________________________________________

Home Phone #____________     Student Cell Phone #____________     Current Grade:   ___________

School Name_________________________   StudentEmail__________________________________ 

Family Email__________________________________________ 

Parent/GuardianInformation

Mother’s Name _____________________________      Father’s Name __________________________

Home _______________ Cell _______________          Home_______________Cell ______________

          Work________________________                                       Work _______________________                                   

If you can’t be reached, call________________________________ Relationship:_________________

Home______________________   Cell_______________________  Work_______________________

Medical Information

Insurance Carrier ___________________________________    Policy Number _________________

Insurance Carrier’s Phone _____________      Date of Last Tetanus Shot ______________________   

Primary Doctor __________________ Phone____________ 

Medical, emotional or mental issues we should know about  (ex: depression, diabetes, sleepwalking, etc)?

_______________________________________________________________________________

Allergies to food/environment orspecial needs we should know about to care for your child?_______________________________________________________________________________

Medications: ___________________________________________________________ 

My child canbe given basic analgesics (Tylenol, Advil, Benadryl)    Yes     No

Release FromLiability

I give permission for my child ______________________________to participate in Youth Activities at St. Paul Lutheran Church.  I understand and consent to any field tripsthat he/she will take in St. Paul approved vehicles and agree to ensure theirpunctual arrival and pickup.  I permitSt. Paul Lutheran Church to use video or photographs of my child for churchrelated materials.  I hereby release St.Paul Lutheran Church, its staff and volunteers, from any liability for injurythat my child may sustain during activities or field trips.  In case of illness or injury, and in theevent I am unable to respond, I authorize St. Paul staff and volunteers toallow emergency medical treatment or surgery by a licensed physician orhospital.  Should it be necessary for the participant to returnhome due to medical reasons, disciplinary action or otherwise, we (I) herebyassume all transportation costs.

_________________________________         ____________________________________

Mother’s Signature                             Date         Father’s Signature                                   Date

Please read and sign the following sheet also.

SPYPolicy and Procedures

GeneralGuidelines:

1.    YearlyLiability forms need to be filledout by a parent/guardian to participate in Youth Group Activities.

2.  When traveling away from the church, the Same-Gender Buddy System will be used.  Each student will have another student of the same gender as a buddy.  Your buddy will know where you are at all times and be your companion during the event, however your buddy may change during the event.  The Same-Gender Buddy System is subject to change based on the event and authorization from Youth Director.

3.    Same-Gender Seating will be used whiletraveling, but may be subject to change depending on trip and approved by YouthDirector.

4.    Therewill be no romantic public displays of affection (PDA).

5.    No alcohol, tobacco, controlledsubstances or weapons permitted on church property or at events (applies tostudents and adults).  All medicationsshould be given to adult leader while traveling.

6.    Violent,destructive, or inappropriate behaviortowards yourself, another person or property will not be accepted.

7.   Youth dressand appearance is expected to be modest.

Thefollowing examples of clothing are NOT ACCEPTABLE at youth sponsoredactivities.

›Tops that reveal bare midriff and plunging necklines. 
All tops should modestly cover the upper torso.

›Shorts, dresses, and skirts shorter than mid-thigh in length (general guidelinefor most would be finger tip length with arms fully extended at the student’ssides).

› Swimsuits with plungingnecklines.  (Must wear one-piece modestswimsuits.)

› Clothing that displaysoffensive pictures and language.

If astudent’s appearance is determined to be inappropriate, he/she will be asked tochange into appropriate clothing.

Discipline:

1.  First Time Offense:  Verbal Warning.  Leader speaks to student and addresses situation.

2.  Second Time Offense:  Call Home.  Leader calls home and speaks to parent, and the parent speaks to the student.

3.  Third Time Offense:  Student Goes Home.  Student is picked up by parent or sent home at the parent’s expense. 

If the situation is serious,the parent will be notified immediately and the student will be picked up bythe parent.

I have read and understand the above policies and guidelines.

__________________________________          __________________________________

Youth’s Signature                            Date               Parent’s Signature                      Date