MedicalReleaseforYouthEventsandParticipantInformationAugust 2014-August 2015
Returnto: Leah Romanelli• Youth Minister •470 Maple St.•Winnetka,IL60093 • fax:847-446-8640 •
ParticipantName(pleaseprint)Male/Female
DateofBirth
T-Shirt Size
GradeinSchool2013-2014
Address
City, State,ZipCode
HomePhone#
YouthCellPhone#
YouthEmail
Parent/GuardianEmail
Parish/Church
HealthInsuranceCompany
Policy#
Insured’sname
Youthrelationshiptoinsured
FamilyPhysician
PhysicianPhone daytime/afterhours
EmergencyContact / Name(Pleaseprint) / HomePhone# / WorkPhone# / CellPhone#
Parent/Guardian
Parent/Guardian
EmergencyContact / Name(Pleaseprint) / HomePhone# / WorkPhone# / CellPhone#
EmergencyContactifparentcannotbe reached &relationship to youth
SpecialMedicalConcerns(thatmightlimitparticipationorbeimportantinanemergency)
DietaryRestrictions
Vegetarian / YesNo
Allergies
please copy down this contact information in case of emergency during the event:
Christ church: 470 maple st. winnetka, il 60093+ 847-446-2850 (office) + 847-446-8640 (fax)
Leah Romanelli (youth ministeR): + 815-757-7567 (cell)
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Thefollowingisalistofmedicationsyouthparticipantwillneedtotakewhileattendingevents:(pleaseattach listifadditionalroomisneeded)
Medicationstobeadministered / Dosage / Times•Allprescriptionmedicationmustbeproperlylabeledinitsoriginalpharmacycontainer.
•Overthecountermedicationshouldbelabeledwithparticipantnameoncontainer.
PermissiontoreceiveOTCmedications:Igivemypermissionformychildtoreceiveoverthecountermedications fromadultstaffatevents,suchasTylenol,ibuprofen,coughdrops,Mylantaetc.
please copy down this contact information in case of emergency during the event:
Christ church: 470 maple st. winnetka, il 60093+ 847-446-2850 (office) + 847-446-8640 (fax)
Leah Romanelli (youth ministeR): + 815-757-7567 (cell)
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Parent/GuardianSignature
Date
please copy down this contact information in case of emergency during the event:
Christ church: 470 maple st. winnetka, il 60093+ 847-446-2850 (office) + 847-446-8640 (fax)
Leah Romanelli (youth ministeR): + 815-757-7567 (cell)
PaGe 1
ParentalConsent:IgivefullpermissionformychildtoattendChrist Church Winnetka Youthevents,includingbutnotlimitedto: service projects, community outings,Jr.High/Sr.HighRetreats,MissionTrips, Diocesan eventsandothereventsnamedhere: ______
Photo/VideoPublicityReleaseStatementYESNO
IgivemypermissionforphotographsorvideofootageofmychildtobeusedbytheDioceseofChicagoforpromotional purposes.(Brochures,websitephotos,promotionalvideos,etc.)Nonamesareusedonwebsitephotosorin publicity.
ParticipantRosterYESNO
Igivemypermissionformy child’saddress/phonenumber/emailtobeincludedonaparticipantrosteroftheevent(foruseofparticipantsonly)
TransportationRelease
Igivefullpermissionformychildtobetransportedtoyouthactivitiesinconjunctionwiththeabovementionedevents,awayfromourmeetingsite,ridinginapprovedvehicles,withapproveddriversintheDioceseofChicago,andtoattend andparticipateinactivities off siteofourmainprogram.
WaiverofLiability
To the maximum extent permitted by law, IagreetoholdtheDioceseofChicago, Christ Church, Winnetka,andanyassociatedor affiliated agenciesandpersonsfreeof, andto waive,anyand all claimsof my own, my spouse, or of my child for paymentforaccidental or wrongful death,injury,disability, ordamagestomyself, to my spouse or to thepersonorpropertyoftheaforementionedchildarisingoutoforconnectedwithhis/herparticipationinanyactivityrelatedtohis/herparticipationintheaforementioned activity. To the maximum extent permitted by law, I freely and knowingly agree to submit to mandatory and binding arbitration any claims of my own, of my spouseand of my child, arising from or related to this Release, all claims included in this Release and waiver of liability and all claims related to the enforcement and enforceability of this Release and waiver of liability. I agree that any such arbitration shall proceed exclusively in Chicago, Cook County, Illinois, before a single arbitrator employed by or affiliated with JAMS and in accordance with JAMS Streamlined Arbitration Rules & Procedures (eff. July 15, 2009). I freely and knowingly waive, for myself, my spouse and my child, any and all rights to assert any such claims in any court or other judicial tribunal and I further waive any rights of my own, my spouse and my child to any jury trial of any claim, damage, action or cause of action subject to arbitration under this Release and waiver of liability.
Parent/GuardianSignatureDate
please copy down this contact information in case of emergency during the event:
Christ church: 470 maple st. winnetka, il 60093+ 847-446-2850 (office) + 847-446-8640 (fax)
Leah Romanelli (youth ministeR): + 815-757-7567 (cell)
PaGe 1
YouthEventCovenant
Thefollowingcovenanthelpsprovideforthephysical,emotional,andspiritualsafetyofour Christ ChurchYouthCommunity.Allparticipantsagreetoactivelyparticipateinallpartsoftheeventandtoabidebythestandardsofthe community, whichareasfollows:
1.Iwillrespectandfollowtherulesfortheevent.
2.Iwillrespectthephysicalpropertyofthe facility,andthepropertyofeachpersonattheevent.
3.Iwillremainonthepremisesandbeanactiveparticipantinallscheduledactivitiesforthe event.
4.Iwillwearappropriateclothing.
5.Iwillhandinallprescriptionmedicationtotheeventnurse.
6.Iwillnotenterthesleepingareasoftheoppositesex.
7.Iwillnotengageinsexualbehavior, includingsexualmisconduct,sexuallyexplicitcommunication,orharassment.
8.Iwillnotuseorbeinpossessionofalcohol,illegaldrugs,ortobacco.
9.Iwillnotbringanythingthatcouldbeconsideredaweapon,suchasfirearms,knives,pocket-knives,orfireworks.
10.Iwillnotparticipateinactsofviolence,aggression,orfighting.
TheseStandardsapplytoalladultandyouthparticipants.
BysigningbelowI agreethatthese arereasonableexpectations andIwill doeverythingI cantolive uptothem.IfIchoosetoviolatetherulessetfortheeventIamplanningtoattend,Iunderstand thattherewillbeconsequences,whichmayincludemybeingsenthomeatmyownexpenseand withoutrefund.
ParticipantSignature:Date:
Asparentand/orlegalguardianofthischildIhavereadtheaboveandbelievethathe/sheis capableofaspiringtoandfollowing thesecommunityexpectationsandrules.Ialsounderstandthatifmychildfailstomeettheseexpectations,Iwillbecontactedandaskedtobringmychildhome fromtheevent.
Parent/GuardianSignature:Date:
please copy down this contact information in case of emergency during the event:
Christ church: 470 maple st. winnetka, il 60093+ 847-446-2850 (office) + 847-446-8640 (fax)
Leah Romanelli (youth ministeR): + 815-757-7567 (cell)
PaGe 1