Youth AFIRE
(Acting Faithfully, Inspiring Radical Eco-justice)
-presented by the-
Massachusetts Conference of the United Church of Christ
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Youth AFIRE is not an overnight event, thus the onus is on individual churches to secure permissions slips from their participants as they would for any other youth event. We require a completed Photo Release Form (below) be submitted for each individual and ask that youth leaders and/or chaperones have medical information for all youths. We have provided an optional Medical Release and Consent Form on the back in case your church does not have one readily available.
Youth AFIRE Photo Release Form
Mandatory
We hope you agree to us using digital photos and video to retell and promote your experience at Youth AFIRE. We may submit news stories to publications and add information to our website; however, we will respect your wishes if you choose not to give us that permission. Photos are generally taken by the leaders and/or participants at the retreat but not all photos are used. We do not maintain print copies and NOT all photos will be used.
I give / do not give (circle one) the Massachusetts Conference of the United Church of Christ and its agents my permission to take my child’s photo using a video camera and/or digital still camera for purposes of promotion and news publications. Participants in the photos/video will NOT be individually identified.
I hereby release the Massachusetts Conference of the United Church of Christ, its employees and agents from any and all claims for damages, libel, slander, invasion of the right of privacy, or any other claim based on the use of the photos or video.
No promises have been made to me in exchange for my signature on this release. I understand the purpose of participation in these photos and/or video. I have read this release and fully understand the meaning of it.
I am the parent/guardian of ______(please print name of child), who is a child under the age of eighteen. I grant permission for my child to be included in any and all media which has been or will be made by the Massachusetts Conference of the United Church of Christ.
Parent/Guardian Signature: ______Date:______
Parent/Guardian Name (please print): ______
Church Name and Location: ______
Medical-Release and Consent Form
Optional - Use this or your own church’s form
Name of youth______Date of birth ____/ ____/ ____
First Nickname Middle Last
Address______Contact phone______
Name of parent or guardian______
Youth’s physician______Phone______
Emergency contact #1______Phone______
Relation to youth______
Emergency contact #2______Phone______
Relation to youth______
Health history (please check all that apply)
Frequent colds Seizure disorders Physical disability Appliances (retainers, contact lenses, etc.)
Stomach upsets Diabetes Mental disability Vision/hearing impairment
Asthma Sleep disturbances Motion sickness Emotional/behavioral disability
Other______
Allergies______
If any of the above are checked, please give important details______
______
Date of last Tetanus shot______
Is your son/daughter taking a prescription or non-prescription medication? yes no
If yes, please answer the following:
1. Medication______
Dosage and Frequency of dosage______
2. Medication______
Dosage and Frequency of dosage______
3. Medication______
Dosage and Frequency of dosage______
Can your son/daughter be expected to take the right amount of medication at the proper time? yes no
If the answer is no, arrangements must be made with the adult in charge.
I give my child permission to administer his/her own medications______
Signature of Parent/Guardian
Youth’s insurance carrier and policy number______
Name of primary insured______
STATEMENT OF CONSENT
I, the undersigned, parent/legal guardian of ______do hereby consent to any x-ray exam, anesthetic, medical diagnosis or treatment and hospital services that may be rendered to said minor, under the general or specific instructions of ______(name of youth’s physician) or, if unavailable, two on-call physicians at a hospital or clinic. It is understood that this consent is given in advance of any specific diagnosis or treatment and is given to encourage those persons who have temporary custody of my child, in my absence, and said physician to exercise their best judgment as to the requirements of such diagnosis or said medical treatment.
This consent will remain effective until the 15th day of May 2016, delivered to said persons entrusted with the care, custody and control of said minor child. I understand that any and all medical expenses incurred are my responsibility and that there is not medical insurance coverage provided by The Massachusetts Conference of the United Church of Christ.
Parent/Guardian Signature: ______Date:______
Parent/Guardian Name (please print): ______
Church Name and Location: ______