Youth Ministry Universal Permission Form
St. Luke’s Episcopal Church
8009 Fort Hunt Road, Alexandria, VA 22308
Effective Dates: September 1, 2015 — August 31, 2016
A completed Universal Permission Form is required in order for any youth in 6th-12th grades to participate in a St. Luke’s Episcopal Church sponsored youth ministry event. Once submitted, this form is kept on file until the expiration date above. Provide the Assistant Rector updated information as changes occur. Return completed forms to the Assistant Rector at the address printed above.
Youth Information (please print)
Youth’s Name ____________________________ Nickname__________________ Grade ____
DOB _______________ School _______________________________________ Male/Female
Youth’s Email _________________________________________________________________
Youth Home Phone ________________________ Youth Cell Phone _____________________
Parent/ Guardian Information
Parent Email(s) ________________________________________________________________
List ALL parent/guardians phone numbers in the best order to be reached (please specify type i.e. home, dad’s cell):
Phone #1 _______________________________ Type? ___________________
Phone #2 _______________________________ Type? ___________________
Phone #3 _______________________________ Type? ___________________
Phone #4 _______________________________ Type? ___________________
Phone #5 _______________________________ Type? ___________________
Non-Parent Emergency Contacts
Name_________________________ #_______________________ Relation? _____________
Name_________________________ #_______________________ Relation? _____________
Parental Consent (Read and sign below)
The undersigned does hereby give permission for my child ____________________________ (child’s name)(“Participant”), to attend and participate in any St. Luke’s youth ministry activities, events, and retreats during the period of September 1, 2015 – August 31, 2016.
LIABILITY RELEASE: In consideration of St. Luke’s allowing the Participant to participate in youth ministry (Sunday worship, Sunday meeting, Activities, Events, Retreats, Lock-Ins, Trips), I, the undersigned, do hereby release, forever discharge and agree to hold harmless St. Luke’s, 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.
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 youth pursuant to this authorization.
EARLY RETURN HOME POLICY: Should it be necessary for my child 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 child to ride in any vehicle driven by an approved and licensed ADULT chaperone (21 years of age or older) while attending and participating in activities sponsored by St. Luke’s. My child and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.
PHOTO PERMISSION: During Youth Ministry events, staff or volunteers will sometimes take photos or video of youth participating in various activities. These images may be used by St. James’s for online and/or print publications. Youth will not be identified by name in publications.
Yes. I give permission for my child’s photos to be used as described.
No. I do not want such images published of my child.
Signature of Parent/Guardian Date
YOUTH INFORMATION (Please Print)
Youth’s Full Name ________________________________________________ DOB _______________
PRIMARY CARE PHYSICIAN
Physician’s Name _____________________________________________________________________
Phone(s) _____________________________________ Fax ___________________________________
Name of practice _____________________________________________________________________
Date of last Tetanus shot (required) ______________________________________________________
Medical Insurance Company: ____________________________ Phone: ______________________ Policy/Group ID#: _________________________________________________________________ Policy Holder’s Name (please print): ____________________________________________________
Copy of Insurance Card (required)—Paste/attach copy here:
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 during a youth event. If this occurs, the youth will be sent home immediately at the parent/guardian’s expense.
Medication Name Dose Treatment for Dispensing instructions
Example: Zyrtec 5mgSeasonal allergies Take one pill daily in the morning with food _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Over-the-Counter Medication Permission: Do you give permission for your child/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.
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.
MEDICAL CONDITIONS: Please answer in detail if applicable or write N/A. Attach additional pages if necessary.
1. List any medical conditions of youth (asthma, knee injury, epilepsy, wears contacts, etc.):
2. List any allergies and the severity and type of reaction (drug/medicine, food, environmental):
3. 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.
Youth Ministry Covenant of Community Expectations
The following rules and guidelines are equally binding for youth and adult leaders/chaperones.
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 (or Adult Leader’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.
Youth Participant’s (or Adult Leader’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.
Parent/Guardian’s Signature Date