MEDICAL AND LIABILITY RELEASE

FaithCommunityChurch

2931 Lucerne Dr.Janesville, WI53545

Name: ______, ______, ______

LastFirstMiddle

Address: ______, ______, ______

StreetCityZip

Home Telephone (____) _____-______Date of birth ___/___/___ Grade: ______

Name of Parent/Legal Guardian ______

Are there any medical conditions/medications/allergies that the church should be aware of? ____If so, please describe: ______

MEDICAL INSURANCE INFORMATION:

Insurance Company ______(____) ____-______

Name Phone Policy Number

Family Physician or Other Health Provider ______(____) ____-_____

Name Phone

EMERGENCY CONTACT PERSONS:

______(____) ____-______

Name Phone Relationship

______(____) ____-______

Name Phone Relationship

Is there any person(s) who is restrained by court order from picking up this minor?____

If so, what is the name of the person?______

MEDICAL AND LIABILITY RELEASE:

In agreeing to participation by my child/ward ______in any activity sponsored by FaithCommunityChurch, on the church grounds or off, I realize that the programs are staffed by trained volunteer workers and care is taken to assure that minors are safe during supervised activities; however, mishaps can occur. I accept full behavioral and financial responsibility for my child and recognize that the church insurance is secondary to my own.

I authorize and consent to any x-ray examination, anesthetic, medical, or surgical treatment rendered by any member of a medical staff, emergency room, or care center under general supervision of any duly licensed member of the medical profession. I also authorize general treatment and first aid by any person holding a current certification to do such. I understand that effort shall be made to contact persons listed above prior to treatment, but treatment will not be withheld if contact is not possible. The parents/guardians understand that they are signing for the minor listed on this form and that the signature is for both a medical and liability release.

Parent/Legal Guardian:______Date: ___/___/___

Signature

This consent shall remain in effect eighteen (18) months from the date signed.

The signature on this form indicates that the parents/guardians have read and understand the rules and consequences listed on the reverse of this form.

All-Stars Youth Ministry

We exist to REACH students, to CONNECT them with Christians, to challenge them to GROW in their faith, to DISCOVER an area of ministry, and to live a life that is HONORING to God.

Everyone will respect the leaders of the youth group. This means:

  • Listening quietly to the leaders when they are speaking.
  • Doing what the leaders ask you to do.
  • Not talking back to the leaders.

Everyone will respect the other young people around them. This means:

  • No horseplay or physical violence
  • No yelling, cursing, or name calling
  • Treating your peers with dignity and respect at all times

Everyone will respect the church property. This means:

  • Taking care of the equipment
  • Not throwing trash on the floor or the Church grounds
  • Not tampering with anything on the Church grounds – Including cars

No use of audio equipment at youth group functions.

Consequences:

First offense:Warning

Second offense:Kicked out of that session or youth activity

Third offense:Kicked out of youth activities for a month

Fourth offense:Not allowed at any youth functions until a meeting with Youth Pastor, student, and parents is held.

No illegal substances or weapons of any kind are allowed. This means:

  • Any persons suspected of knowingly bringing or being under the influence of any illegal substance at any church function will be subject to the following:

Search

Confiscation

Notification (Parents and /or Police)

Restriction from the youth group

  • Any persons suspected of knowingly bringing any weapons to any Church functions will be subject to the following:

Search

Confiscation

Notification (Parents and /or Police)

Restriction from the youth group

Ongoing discipline problems:

  • Talk to parents with youth leader and or Pastor Michael
  • Leave the youth group for a set amount of time, depending on the circumstance.

September 2012