Youth Medical Form Mission Trip 2013
Content
Corpus Christi Church__________________________
Youth Ministry Office 1415 Lies Road Carol Stream, Illinois 60188 630-483-4226 [email protected]
Youth Permission and Medical Form July 20 – 27, 2013
GENERAL PERMISSION FORM
I request that my child: _______________________________________________ be allowed to participate in 2013 Corpus Christi Church Mission Trip. I hereby release and indemnify Corpus Christi Church its staff, volunteers, and the Diocese of Joliet from any and all liability arising from claims of any kind or nature whatsoever from my child's participation in this trip.
MEDICAL PERMISSION FORM
I grant permission for the administration of First Aid to my child, _____________________________________, by the people in charge of the 2013 Mission Trip, and those transporting my child to and from the event as their judgment deems advisable, and to make the necessary referrals to qualified physicians for the treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In the case of a medical emergency, I understand that every effort will be made to contact the parent/guardian of the participant. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery if deemed necessary for my child.
Videotaping and Still Photographs
Video and still photographs may be taken during this event. This authorization form constitutes permission for my child's participation in the videotape and/or still photographs, which may be used for future promotional efforts, including the Corpus Christi Church website.
Code of Behavior
You are representing Youth Ministry in our diocese during this event and we expect you will represent us well. We expect that you will display mature and responsible behavior, which for many years has been the trademark of Catholic youth and adults of our diocese.
Some Expectations: 1. All participants are expected to arrive on time. 2. All participants are expected to demonstrate common courtesy and respect at all times. Inappropriate language/behavior will not be tolerated. 3. Socializing should always be done in public areas. 4. Dress should reflect the value of modesty. Writing on clothing should reflect Christian values. 5. The possession or consumption of any alcoholic beverage and/or possession/use of any illegal drug is not permitted. 6. Smoking is not permitted. 7. Weapons and/or drug paraphernalia are not allowed. 8. If under the age of 18, prescription drugs need to be given to an adult from your parish for storage and distribution. 9. Infraction of these rules can mean immediate dismissal with no refund. Participants will be responsible to local authorities as well. I understand and agree to this Code of Behavior. I also understand and agree that at the time of an infraction requiring my dismissal, I am responsible for my removal from the premises and any costs involved. If under the age of 18, I also understand and agree that my parents or guardian will be notified at the time of an infraction requiring my dismissal. My parents or guardian will be responsible for my removal from the premises and any costs involved.
Parent/Guardian Signature: _____________________________________________ Date: ________________________________ Teen’s Birth Date: ___________________________ Allergic to medication/other? NO YES If yes, please describe: Medication(s) presently taking: Insurance Information Policy in the name of: ___________________________ Insurance Company: ____________________________ Policy Number: ________________________________ Identification Number: __________________________ Authorized Physician: __________________________ Phone #: _____________________________________ Parent/Guardian Signature: ____________________________________________ Address: ____________________________________ City:___________________ State: ____ Zip:_________ Home Phone: __________________________________ Work Phone: __________________________________ Cell Phone: ___________________________________ Another Emergency, contact Name: _____________________________________________
Youth Signature: _____________________________________________ Date: ____________ Parent/Guardian Signature: _____________________________________________ Date: ____________ Please print Parent/Guardian Name:
_________________________________________ _
Phone #’s: ________________________
Youth Ministry Office 1415 Lies Road Carol Stream, Illinois 60188 630-483-4226 [email protected]
Youth Permission and Medical Form July 20 – 27, 2013
GENERAL PERMISSION FORM
I request that my child: _______________________________________________ be allowed to participate in 2013 Corpus Christi Church Mission Trip. I hereby release and indemnify Corpus Christi Church its staff, volunteers, and the Diocese of Joliet from any and all liability arising from claims of any kind or nature whatsoever from my child's participation in this trip.
MEDICAL PERMISSION FORM
I grant permission for the administration of First Aid to my child, _____________________________________, by the people in charge of the 2013 Mission Trip, and those transporting my child to and from the event as their judgment deems advisable, and to make the necessary referrals to qualified physicians for the treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In the case of a medical emergency, I understand that every effort will be made to contact the parent/guardian of the participant. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery if deemed necessary for my child.
Videotaping and Still Photographs
Video and still photographs may be taken during this event. This authorization form constitutes permission for my child's participation in the videotape and/or still photographs, which may be used for future promotional efforts, including the Corpus Christi Church website.
Code of Behavior
You are representing Youth Ministry in our diocese during this event and we expect you will represent us well. We expect that you will display mature and responsible behavior, which for many years has been the trademark of Catholic youth and adults of our diocese.
Some Expectations: 1. All participants are expected to arrive on time. 2. All participants are expected to demonstrate common courtesy and respect at all times. Inappropriate language/behavior will not be tolerated. 3. Socializing should always be done in public areas. 4. Dress should reflect the value of modesty. Writing on clothing should reflect Christian values. 5. The possession or consumption of any alcoholic beverage and/or possession/use of any illegal drug is not permitted. 6. Smoking is not permitted. 7. Weapons and/or drug paraphernalia are not allowed. 8. If under the age of 18, prescription drugs need to be given to an adult from your parish for storage and distribution. 9. Infraction of these rules can mean immediate dismissal with no refund. Participants will be responsible to local authorities as well. I understand and agree to this Code of Behavior. I also understand and agree that at the time of an infraction requiring my dismissal, I am responsible for my removal from the premises and any costs involved. If under the age of 18, I also understand and agree that my parents or guardian will be notified at the time of an infraction requiring my dismissal. My parents or guardian will be responsible for my removal from the premises and any costs involved.
Parent/Guardian Signature: _____________________________________________ Date: ________________________________ Teen’s Birth Date: ___________________________ Allergic to medication/other? NO YES If yes, please describe: Medication(s) presently taking: Insurance Information Policy in the name of: ___________________________ Insurance Company: ____________________________ Policy Number: ________________________________ Identification Number: __________________________ Authorized Physician: __________________________ Phone #: _____________________________________ Parent/Guardian Signature: ____________________________________________ Address: ____________________________________ City:___________________ State: ____ Zip:_________ Home Phone: __________________________________ Work Phone: __________________________________ Cell Phone: ___________________________________ Another Emergency, contact Name: _____________________________________________
Youth Signature: _____________________________________________ Date: ____________ Parent/Guardian Signature: _____________________________________________ Date: ____________ Please print Parent/Guardian Name:
_________________________________________ _
Phone #’s: ________________________
