2009-10 Youth Permission Form

701 Beach Drive NE St. Petersburg, FL 33701 727.822.2031 Fax: 727.894.2971

YOUTH PERMISSION FORM

Effective Dates: 9/1/09 to 8/31/10

Youth Name _________________________________ Age _____ Birthday ___________ Grade________

ˆ Female ˆ Male

Email ______________________________________

Address ______________________________ City__________________ Zip Phone _______________________________ Cell

_________

______________________________

Mother’s Name ______________________________ Phone ___________________ Office ___________________ Address

(if different from above)

Cell __________________

__________________________________________________

Father’s name ________________________ Phone ___________________ Office ___________________ Address

(if different from above)

Cell __________________

__________________________________________________

Emergency Contact: _______________________ Phone ___________________ Office ___________________

Cell __________________

CONSENT TO EMERGENCY MEDICAL CARE I hereby give my consent to any physician, emergency personnel and healthcare facility to provide medical care to my child, ___________________________________________, in the event of an emergency. I give consent to transport by ambulance if the situation warrants it. In addition, I agree to be financially responsible for any medical expenses that are incurred in the treatment of my child. Physician ________________________________ Phone _________________________________ Dentist _________________________________ Phone _________________________________ Allergies ________________________________________________________________________ Date of last DPT or Tetanus shot ____________________ Are there any other medical or emotional considerations that we should be aware of? _______________________________________________________________________________ Medical Insurance Company ____________________________ Policy Number

____________________________________

AUTHORIZATION TO PARTICIPATE IN YOUTH ACTIVITIES RELEASE AND INDEMNIFICATION I understand that there are inherent risks involved in any youth activity or event in which the Youth participates, whether on or off the premises of First Presbyterian Church of St. Petersburg (Church). On behalf of the Youth desiring to participate in Church sponsored activities for Youth, held on or off Church premises, and in consideration of the Youth's participation in and being provided transportation to said activities, the undersigned parent or guardian hereby releases Church and its ministry staff, employees, members, volunteers or agents from, and agrees to indemnify, defend and hold harmless Church and its ministry staff, employees, members, volunteers or agents from and against any and all demands, claims, causes of action (including any personal injury or damage to property), fines, penalties, damages (including consequential damages), liabilities, judgments, and expenses (including without limitation attorneys' fees) arising from or in connection with the Youth's participation in Church-sponsored activities whether conducted on Church premises or off the Church's premises. The undersigned voluntarily and knowingly executes this release and indemnity agreement on behalf of the Youth with the express intention of extinguishing the rights and obligations designated herein. I also agree to permit supervision and transportation of the Youth in accordance with Church policy. Additionally, unless I expressly deny the Church authority to use photographic or other digital representations of the Youth, I grant my consent to use the same by the Church for any purpose, including display on Church authorized web sites.

COVENANT OF CONDUCT In all meetings, retreats or other events under the sponsorship and/or guidance of the Church, I am representing the Christian community and I am responsible for my actions. I understand the following guidelines will be followed: 1. 2. 3. 4. 5.

No use or possession of illegal drugs, alcoholic beverages and tobacco. All conduct will respect property, one another, staff, adult leaders, schedules and event rules. No fighting, weapons, fireworks, lighters or explosives. No offensive or immodest clothing. Participation with the group and in the activities is expected.

I, the above named Youth, understand the above Covenant of Conduct and I agree to abide by it to the best of my ability. Youth Signature ________________________________________ Date ____________________ We (I), as parents (guardians), understand all three parts of this agreement. If the Youth disregards the Covenant of Conduct, a serious attempt to contact all the above phone numbers will be made and plans to pick up the Youth will be arranged. If we (I) are unavailable for contact or refuse to pick up the Youth, the current most available transportation carrier will be used at my expense to return the Youth home. Parent (Guardian) Signature_______________________________ Date ____________________ Print Name ____________________________________________ STATE OF FLORIDA, COUNTY OF ___________________________ The foregoing instrument was sworn to and subscribed before me this ____ day of ____________, _____, by _____________________, who is personally known to me or who has produced _________________________ (type of identification) as identification.

NOTARY PUBLIC, STATE OF FLORIDA