St. Jude’s Episcopal Church Youth and Children Events
Medical Release Form
Full Name: O Male O Female
Street Address: Age:
City, State, Zip Code: DOB:
Student Email: Parent Email:
Home Phone: Emergency Phone:
Cell Phone (s):
Parent/Guardian’s Full Name :
Alternate Emergency Contact: Phone:
I give permission to representatives of St. Jude’s Episcopal Church in charge of this program to take my child to the nearest physician or emergency medical facility in the event that the person authorized by law is not available to give consent for necessary medical treatment, whether or not of an emergency nature. I give permission to the physicians and staff of the medical treatment facility selected by the representative(s) of the Church to hospitalize my child or to administer or secure proper treatment (including but not limited to: over the counter medication, injection, anesthesia, prescriptions, surgery, or dental work) which the attending physician recommends as reasonable. I understand that notification of parents or guardians will take place as soon as possible. My child may participate in all activities except as noted below under “Special Restrictions”.
Parent/Guardian Signature: Date:
Medications being taken:
Note: All medications being taken (prescription or over the counter) must be turned over to an adult to be administered per directions.
Allergies:
(Food, drug, chemical, insect bites, etc. If allergic to bees, Epi or other kit must be provided for outdoor activities)
Special Restrictions or dietary concerns:
Can this person swim? OYes O No
If yes, specify level: Beginner Intermediate Advanced
Insurance Carrier: Policy/Group #:
Return Completed Forms to:
St. Jude’s Episcopal Church
Attn: Cassandra Crosby
200 N. Partin Dr.
Niceville, FL 32578
(850) 678-4705 (office)
(850) 678-0922 (Fax)
Or email completed form to:
Youth@st.judes.us
Medical Release Form
Full Name: O Male O Female
Street Address: Age:
City, State, Zip Code: DOB:
Student Email: Parent Email:
Home Phone: Emergency Phone:
Cell Phone (s):
Parent/Guardian’s Full Name :
Alternate Emergency Contact: Phone:
I give permission to representatives of St. Jude’s Episcopal Church in charge of this program to take my child to the nearest physician or emergency medical facility in the event that the person authorized by law is not available to give consent for necessary medical treatment, whether or not of an emergency nature. I give permission to the physicians and staff of the medical treatment facility selected by the representative(s) of the Church to hospitalize my child or to administer or secure proper treatment (including but not limited to: over the counter medication, injection, anesthesia, prescriptions, surgery, or dental work) which the attending physician recommends as reasonable. I understand that notification of parents or guardians will take place as soon as possible. My child may participate in all activities except as noted below under “Special Restrictions”.
Parent/Guardian Signature: Date:
Medications being taken:
Note: All medications being taken (prescription or over the counter) must be turned over to an adult to be administered per directions.
Allergies:
(Food, drug, chemical, insect bites, etc. If allergic to bees, Epi or other kit must be provided for outdoor activities)
Special Restrictions or dietary concerns:
Can this person swim? OYes O No
If yes, specify level: Beginner Intermediate Advanced
Insurance Carrier: Policy/Group #:
Return Completed Forms to:
St. Jude’s Episcopal Church
Attn: Cassandra Crosby
200 N. Partin Dr.
Niceville, FL 32578
(850) 678-4705 (office)
(850) 678-0922 (Fax)
Or email completed form to:
Youth@st.judes.us
Covenant of Conduct
In signing this covenant, I understand and agree to live by the guidelines listed below during regular and special Youth and Children events. I will:
+Remember that I am a representative of St. Jude’s Episcopal Church and will conduct myself in a manner that befits a Christian person, and,
+Respect the health and sacredness of my own body by refraining from the use of any illegal drugs (including the misuse of prescription drugs), tobacco products, or alcohol, and,
+Respect the physical and emotional well-being of other youth and adults by modeling positive spiritual principles such as: love for one another, trust, integrity, and confidentiality, and,
+Respect the safety of myself and others by not possessing or using fireworks or any other explosives, firearms, or knives that could harm others at any youth activity, and,
+Be responsible for my own behavior and participate fully in all scheduled activities and abide by group decisions made during activities, and,
+Respect myself and the community by refraining from sexual conduct or excessive public displays of affection during activities, and,
+Respect the adults in charge by staying with the group at all times, following all reasonable guidelines set by those in charge of the event and by honoring any reasonable request made of me by the adult advisors, and,
I understand that if my behavior is deemed unacceptable by the adults in charge of an event, I will accept the consequences of my actions which may include my removal from an activity, public apology, and/or being sent home from the event at my parents expense.
Safety Covenant
St. Jude’s Episcopal Church will:
+Conduct background checks and ethics training for every adult involved in supervising young people at the events they sponsor
+Maintain an adult presence at all times in order to provide a physically, emotionally, mentally, and spiritually safe atmosphere for young people involved in events
+Provide a clergy presence for individual counseling and spiritual direction at events
+Utilize accepted safety practices and well-trained facilitators in all physical activities (such as high and low ropes course activities, games, trust and community building activities) in order to provide the safest environment possible
+Provide safe, reliable vehicles and safe, responsible drivers for transportation during events
Young people and their parents will:
+ Agree to hold harmless St. Jude’s Episcopal Church and individuals in the instance of injury to a young person during the course of an event except in the case of gross negligence or intentional act by any of these parties
Youth Signature Date
Parent Signature Date
Clergy/Youth Leader Signature Date
(Required for all staff applications)
In signing this covenant, I understand and agree to live by the guidelines listed below during regular and special Youth and Children events. I will:
+Remember that I am a representative of St. Jude’s Episcopal Church and will conduct myself in a manner that befits a Christian person, and,
+Respect the health and sacredness of my own body by refraining from the use of any illegal drugs (including the misuse of prescription drugs), tobacco products, or alcohol, and,
+Respect the physical and emotional well-being of other youth and adults by modeling positive spiritual principles such as: love for one another, trust, integrity, and confidentiality, and,
+Respect the safety of myself and others by not possessing or using fireworks or any other explosives, firearms, or knives that could harm others at any youth activity, and,
+Be responsible for my own behavior and participate fully in all scheduled activities and abide by group decisions made during activities, and,
+Respect myself and the community by refraining from sexual conduct or excessive public displays of affection during activities, and,
+Respect the adults in charge by staying with the group at all times, following all reasonable guidelines set by those in charge of the event and by honoring any reasonable request made of me by the adult advisors, and,
I understand that if my behavior is deemed unacceptable by the adults in charge of an event, I will accept the consequences of my actions which may include my removal from an activity, public apology, and/or being sent home from the event at my parents expense.
Safety Covenant
St. Jude’s Episcopal Church will:
+Conduct background checks and ethics training for every adult involved in supervising young people at the events they sponsor
+Maintain an adult presence at all times in order to provide a physically, emotionally, mentally, and spiritually safe atmosphere for young people involved in events
+Provide a clergy presence for individual counseling and spiritual direction at events
+Utilize accepted safety practices and well-trained facilitators in all physical activities (such as high and low ropes course activities, games, trust and community building activities) in order to provide the safest environment possible
+Provide safe, reliable vehicles and safe, responsible drivers for transportation during events
Young people and their parents will:
+ Agree to hold harmless St. Jude’s Episcopal Church and individuals in the instance of injury to a young person during the course of an event except in the case of gross negligence or intentional act by any of these parties
Youth Signature Date
Parent Signature Date
Clergy/Youth Leader Signature Date
(Required for all staff applications)
