Date Turned in ___/___/____
PERMISSION:
I hereby give
permission for (_______________________)
to
participate in Student Youth Group and in all related activities. It is
understood that all reasonable caution will be taken by those in charge to
prevent injuries, but neither those persons in charge nor
It is further
agreed that the above student will abide by the rules and regulations, which may
govern each activity and will conduct him / herself in a manner, which is
consistent with the Christian faith.
PARENTAL CONSENT
FOR TREATMENT:
In the event that I
am unavailable for purposes of providing parental consent, I hereby authorize a
representative of St John’s Lutheran Church, Maytown, PA, to consent to and
authorize the administration and performance of all treatments that may be
considered advisable or necessary in the judgment of attending physicians, in
the event that the participant should be admitted to any hospital, or be in need
of any medical treatment. This authorization shall continue for such time as I
am participating in the above student youth program and all related activities,
or during travel to and from said program.
This consent is
valid for 1 year from the date indicated below. A Photostatic or carbon copy of
this authorization shall be considered as effective and valid as the original.
Name of Student
_____________________Date of
Age____
Grade ____ Gender_____ Height: ____
Weight: ____ Eye Color: ______Hair Color: ____
Address
__________________________ PO Box ______City
Mother’s Name
____________________ Phone: Home ___________ Cell __________ Work _________
Father’s Name
____________________ Phone: Home
___________ Cell __________ Work _________
Youth’s E-Mail___________________________ Parent’s E-Mail
________________________________
Can we send you
E-Mail YOUTH ___________
Can we send you E-Mail Parent
___________
Check the following areas of concern for this student. If Necessary, add
another page with details:
Does your youth
wear ____ glasses ____ Contact
Lenses
For your student safety and our knowledge, is your student a---
___ Good Swimmer
____ Fair Swimmer ____ Non
Swimmer
Physical conditions
that the
physician should be aware of, Does your student have allergies to:
Pollens, ______________ Medications, ____________ Food,
____________Insect Bites, _________
Does your student
suffer from, or has ever experienced, or is being treated currently for any of
the following:
Recurring, illnesses, _________ disabilities, ________
chronic illnesses, _________asthma, _______
Epilepsy, / seizure disorder,
________heart trouble _________ physical handicap ___________(ETC)
Current
Medications: ___________________________________________________________________
Will they be on the
trip with the youth? ___________ Date of last tetanus shot ___________________
Should the youth’s
activities be restricted for any reason,
___ Yes ___ No
I understand that I
will be contacted as soon as possible in the event that my student is brought to
a hospital or other facility for treatment. If I am not available, please
contact:
Emergency contact,
name other then Parent, _______________________ Phone No. ______________
Family Physician's
Name: _____________________ Office Phone: _____________________________
Family Dentist
Name: _________________________ Office Phone ______________________________
Insurance Company:
__________________________Policy Number: ___________________________
We are St John’s
Members ________
Friend
Church Denomination___________________
Church Membership At_________________________
(congregation)
Parent/Guardian
signature: __________________________
Date:
___________________
PLEASE MAKE A PHOTO
COPY OF THE MEDICAL CARD (BOTH FRONT AND BACK)
& ATTACH IT TO THIS
FORM!
ALL
EVENT’S AGREEMENT
The Student Youth Program of
St
John's Student Youth Group
is open to all youth from 1st grade to high
school. Some of our student don't regularly attend Church at
·
AS A MEMBER OF THE STUDENT YOUTH
MINISTRY PROGRAM OF
WE AGREE
to support one another and treat each
other in a way consistent with the teachings of Jesus and our church.
·
WE AGREE that when
we are in attendance @ any function (Sunday School, Confirmation Activities,
Student Youth group meetings, Off-site activities &/or Retreats) that we will
attend and participate in all of the activities of that event.
·
FOR REASONS OF SAFETY AND
ACCOUNTABILITY,
WE
AGREE
TO WEAR A SEAT BELT
WHEN RIDING IN VEHICLES FOR ANY CHURCH EVENT, to remain with the student
youth group for the entirety of all classes, activities, events or retreats,
unless accompanied by our advisors. Rough housing or offensive and immodest
clothing is prohibited.
Undergarments including bra straps must not be visible at any time.
No scoop neck styles or plunging
necklines allowed.
Tank tops (3 finger rule) are fine but bellies
must be covered (even though the fashion now is to show it off). Girls, One
piece swimsuits are preferred but due to practicalities 2 piece suits are
permissible.
If a two piece is worn you will be required to wear a colored (non-white)
t-shirt while going to and from the beach or pool. YOU are
not allowed to roll the top down to sun bathe. Shorts and/or skirts need to be
long enough and shirts big enough. Guys are not exempt from the dress code:
Guys swimsuits must be appropriately long
and not have any holes. SHIRTS MUST be warned while
going to and from the beach or pool. No clothing of any kind with any
un-Christian wordage, logos or pictures can be worn. Paints and shorts must be
above the hips. Parents: We need your
help in enforcing this policy -- our staff cannot do it alone! MODESTY is the
key word. No fighting, weapons,
fireworks, lighters, or explosives
·
WE AGREE that
absolutely no tobacco products, alcohol, or drugs (other than prescription
drugs) will be brought to or used at class, activities, events &/OR retreats.
Prescription Drugs will be registered with the adult advisors
·
WE AGREE
to give positive encouragement to fellow youth group
members. Respect one another, advisor, staff, and adult leaders. Help others in
need.
·
WE AGREE that when
we are on retreat we will conscientiously observe curfew and lights out with the
advisors when appropriate.
·
WE AGREE Absolutely no P.D.A.
(public displays of affection) of any form. Put your hormones on hold for all
events..
·
WE AGREE to be a blessing to
others. Disrespect will not be tolerated, a phone call will be made to the
parents to pick you up at their expense and you will be returned home. No
refunds.
·
WE AGREE
THAT WHEN WE ARE ON RETREAT THAT WE WILL
NOT ENTER TENTS, CABINS OR ROOMS BELONGING TO OTHER PARTICIPANTS OR ALLOW OTHER
PARTICIPANTS TO ENTER OUR TENT, CABINS OR ROOMS (MALE&/OR FEMALE); UNLESS THE
DOORS ARE COMPLETELY SECURED OPEN AND AN ADULT IS PRESENT IN THE TENT, CABIN OR
ROOM THE ENTIRE TIME! NO
BEACH TOWL, BLANKET, OR RAFT WILL BE SHARED BY OPPOSITE SEX.
·
WE UNDERSTAND the
privileges of attending classes, activities, events & retreats with
If something is
wrong, tell an advisors, immediately.
THEREFORE,
WE UNDERSTAND that
participants not cooperating or violating this agreement
WILL EITHER BE SENT HOME AT PARENTE
EXPENCE OR PARENTS WILL BE CONSULTED!
WE WILL STRIVE to
help one another keep this covenant!
Cell Phones
may only be used during free
time. This applies to adults as well as youth unless special permission has been
obtained from the event director.
What to Leave at
Home
Your Pet
A bad attitude
All electronic devices
I-Pod, MP3 players etc (with out head seat)
Anything that requires fire to make it work
Anything else you wouldn’t want to be caught with
Youth Signature_________________________________ Date____________
Parent Rules
You are welcome to stay and participate.
HOWEVER, if you choose to stay,
please remember this is your child’s youth group and we encourage them to do as
much as they can for themselves. Keeping in tradition with past youth leaders,
when a parent stays they are no longer a parent, but an equal within the group.
Parent/Guardian
Signature___________________________________________ Date____________
This consent form gives permission to seek
whatever medical attention is deemed necessary, and releases the Church and its
staff of any liability against personal losses of named child. I/We the
undersigned have legal custody of the student named above, a minor, and have
given our consent for him/her to attend events being organized by the Church.
I/We understand that there are inherent risks involved in any ministry or
athletic event, and I/we hereby release the Church, its pastors, employees,
agents, and volunteer workers from any and all liability for any injury, loss,
or damage to person or
property that may occur during the course of my/our child's involvement. In the
event that he/she is injured and requires the attention of a doctor, I/we
consent to any reasonable medical treatment as deemed necessary by a licensed
physician. In the event treatment is required from a physician and/or hospital
personnel designated by the Church, I/we agree to hold such person free and
harmless of any claims, demands, or suits for damages arising from the giving of
such consent. I/We also acknowledge that we will be ultimately responsible for
the cost of any medical care should the cost of that medical
care not be reimbursed by the health insurance provider. Further, I/we affirm
that the health insurance information provided above is accurate at this date
and will, to the best of my/our knowledge, still be in force for the student
named above. I/we also agree to bring my/our child home at my/our own expense
should they become ill or if deemed necessary by the student ministries staff
member.
Parent/Guardian
Signature_____________________________________________ Date____________
Youth Discipline
Policy
With in the programs of syudent ministry at
*Failure to comply with these expectations of behavior will be dealt with
through the following discipline policies and procedure for the student program
and, if warranted, can result in the immediate contacting of the 's parent(s)
and, if on a trip, possibly be cause for an early return via a commercial
carrier (airline or bus) at his/her own expense.
Step 1 – When the behavior first occurs, the adult
observing the behavior, or to whom the behavior is reported, shell address the
person(s) responsible with a clear request that the behavior be stopped,
changed, or avoided. The adult must use judgment as to whether or not the
individual(s) knowingly behaved in a manner inconsistent with the policies. The
preferred method of changing a person’s behavior is to address specifically what
the problem behavior is and what is a preferred option. If a specific person
cannot be identified as the one who behaved inappropriately, the entire group of
individuals associated with the behavior may need to be addressed. The severity
of the problem behavior may require that this step be by passed and the next
step be applied.
Step 2 – If another or the same behavior occurs
involving the same person(s) above, especially when it is considered to be
occurring in a destructive, attention-getting or belligerent fashion, then the
observing/reporting adult is asked to bring the individual(s) to the Youth
Director, or a St Johns Lutheran staff member in leadership, for further
discipline. If no solution is available, then the leader will proceed to the
third step of action, NOTE:
Even if the student(s) agrees to
change the behavior at this point, the parent(s) will be notified by the Youth
Director and advised of the situation regarding their child.
Step 3 – Should there be a third problem behavior
identified, the parent(s) will be called immediately and ask to come, take
custody of the offending student. A conference will be scheduled for the Youth
Minister, parent(s) and the youth(s) involved, to resolve the conflict. This
also applies to the breaking of agreements made in step 2. The church leadership
reserves the right to send home person(s) who are intentionally oppositional or
repeatedly refuse to follow the policies mentioned above for any church event.
The parents will be called immediately and asked to assist with arrangements for
the return of their student(s)
With my signature I acknowledge that I have read these
policies and agree to carefully abide by them and follow their processes.
Signature of Youth Participant:
_______________________________________
Date: _______________
Signature of Parent or Legal Guardian:
_________________________________
Date: _______________
Any student sponsored event
made available through the church youth group requires a deposit by the stated
deadline of at least 1/3rd, of
the cost, or posted cost to guarantee a participating youth a spot for
the event. In this way the student youth group to install some ownership in the
event by the student. Student will realize that they will forfeit this deposit
if they decide at a later date they don’t want to go or if the youth group
advisor(s) decides, based on their behavior, they cannot attend. In the past
we’ve had student/s sign up for an event, but a few failed to go. The result has
been that our student ministry budget has had to cover cost for those who did
not follow through on their prior commitments. Every event/mission organization
requires a deposit and a group total for each trip we attend. Some event/mission
organizations allow groups to drop an individual prior to their deadline, but
others do not. Our church cannot continue to pay the costs for student who
choose not to participate in events to which they had committed
We are keeping track of
those students who are faithful in their participation in student youth group
activities and A.L.I.V.E. night. Through their participation they are “earning”
the remaining 2/3rd, of the cost for their event/mission trip.
Participation includes but is not limited to, attendance in student youth group,
Sunday School, and church service as well as participation as a Sound
Technician, Acolyte, Crucifer, Alter care assistant, Usher, Lector, Praise Band
member, Choir member, and Hand Bell Choir member, and/or Vacation Bible school
staffer, etc. Participation in Crop Walk, fundraisers and assistance in our
mission projects are also ways of earning. The mission project is a way of
showing God’s grace to less fortunate people who need help and I believe will
help to build character in all of us.
Stated below are the
church’s students youth group procedures for refunding monies received for
student youth events.
With my
signature I acknowledge that I have read these policies and agree to carefully
abide by them and follow their processes.
Signature of Student Participant:
_______________________________________
Date: _______________
Signature of Parent or Legal Guardian:
_________________________________
Date: _______________
FOR USE OF PG-RATED, AND PG-13-RATED
MOVIES
As part of
our student ministry program, we will sometimes be using video as discussion
starters.
The movies
may include PG-rated, PG-13, (for 6th-12th grade only).
We will
communicate clearly to our young people that the viewing of this movie is not an
endorsement of the movie. We will voice this disclaimer as well for any PG-13
movies that contain offensive material. If you understand and approve of our
plan to occasionally use videos or video clips from PG-13 or PG-rated movies
when we believe it’s appropriate, please indicate your support by signing and
returning this letter.
Parent/Guardian’s Signature _________________________________ Date
______________________
Parent/Guardian’s Printed Name_____________________________
Phone______________________
St
John’s Lutheran Church Student Youth Ministries
Photo Release and Permission Form
to publish photos
on St Johns Lutheran Website. Our
student youth webpage (www.stjohnsmaytown.com/
) will be a
place you will want to visit for forms, calendars, etc. We would also like to
include occasional photos of youth in action.
I understand that my child’s/student’s name/s WILL NOT
be included with their photos and we ask the student youth not to publish these
names on facebook.
Protecting each student’s privacy and insuring each student’s
safety and well-being will continue to be our first objective!
________ YES, I
giver permission for my student’s photograph to be published on the St Johns
Lutheran Website.
________ NO, I do
not give permission for my student’s photograph to be published on the St Johns
Lutheran Website.
PARENT SIGNATURE:
_________________ DATE: ______________
NAME
___________________________ DATE: _____________
“Our Unity In
Christ”