Holy cross episcopal church
Holy Cross Episcopal Church
Gender: ______Grade (2011-12): _____--_
Youth Email:________________________________ School: ___________________________ Birthdate: _____________ Home Phone:
_______________ Mother Cell:________________________
Father Cell: _______________Parent/Guardian Name(s): _______________________________
(full name of participant), has my permission to participate in all
youth events and activities sponsored by Holy Cross. I understand that all reasonable safeguards will be taken but that Holy Cross Episcopal Church and the leaders of this event are not responsible for accidental injury. In case of medical emergency, I the parent or legal guardian of
authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under, the general or special supervision of any licensed medical personnel on the staff of and any licensed hospital. This authorization is given in advance of any specific diagnosis, treatment or hospital care required, but is given to provide authority and power to render care, which is deemed advisable in the best judgment of the physician. Date:
Signature (Parent should sign in the presence of a notary):
Date of last tetanus shot: ___________Any food or drug allergies: ____________________________ Family Physician: _________________________________Phone: ____________________________ Family Dentist:
Policy Number______________________Special Needs:_____________________________________ Medical Diagnoses or Medication:________________________________________________________ Please check the medications your youth may receive: __Acetminophen (Tylenol), __Ibuprofin (Motrin), __ Naproxen Sodium (Aleve), __ Antihistamines (Benadryl), __Decongestant (Sudafed), __Sore throat spray (Chloraseptic), __Cough Lozenges (Halls Cough drops), __Cough medicine (non-narcotic like Delsym), __Antacids (Malox), __Anti-diarrhea medication (Imodium), __Basic non-invasive first aid (disinfecting creams, topical ointment, sunburn lotion, etc)
If I cannot be reached, please contact:____________________________________________________ Phone: (
Please include a copy of your insurance card
Please have this form signed, notarized and sealed if for an activity or event out of state.
Signature of notary Public_____________ My commission expires ______ Dated____________ Seal of Notary
Holy Cross Episcopal Church
1. I will respect the property, needs and integrity of others; personally, sexually and racially;
and agree not to participate in any inappropriate sexual or violent behavior.
2. I will not bring or use alcohol, illegal drugs or tobacco products of any kind to any event. 3. I will not bring or use firearms, explosives, knives or fireworks. 4. I will not misuse or willfully damage the property of others or the facility or grounds of the
1. I will be present for the entire event and participate fully in all scheduled activities
2. I will not leave the host site or prescribed boundaries without the permission of an adult
3. I will respect and abide by the schedule and expectations of the design team regarding
curfew, quiet times, sleeping areas and equipment use.
4. I will not use electronic equipment during this event, including cell phones, pagers or
personal stereos, etc. as it is disruptive to the community.
5. Once arriving at the event my vehicle will be locked and parked in a designated area for the
6. I will bring an openness to grow in faith, meet new people and have fun.
I understand that the above agreements are designed to make this the best and safest event possible. I promise to adhere to these non-negotiable regulations and expectations while I am a participant at this event. I understand that if I choose to break the non-negotiables at any time during the event I will be removed from the community, my parents will be called and I will be sent home at my own expense. If I choose to break expectations of the event the leaders will determine appropriate consequences. I release Holy Cross to record my/my child’s likeness via still photo, video or audio recordings for use as promotional material for the congregation. I understand that these recordings may be edited at the discretion of the congregation and that they may be published in promotional videos, brochures, brochures, congregational newspapers and congregational websites. I hereby waive all rights to compensation for the use of these recordings. Participants Signature
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