Parent Release Form for EYC (Episcopal Young Christians) activities

For 6 - 12th Grade Students

 

STUDENT APPLICATION

Legal name:
Birth Date:	Month: Day: Year:
Gender:	male  female
Mailing Address:
City:
State:
Zip:
Home Phone:
E-Mail Address:
Name of school you attend:
Grade:
Student Cell Phone:
Father's Name
Father's Address: same as above
Mother's Name
Mother's Address: same as above
Parents Cell Phone:
Parents e-mail:
In Case of Emergency Contact:
Cell phone:

  

There will be a community standard of behavior for all events.  By signing below, you are agreeing to live by the following guidelines for all EYC activities.  If the rules are broken, we reserve the right to notify parents and send the teen home if needed.

1. All participants are expected to fully participate in the event or activity until parent arrives. Any exceptions to this rule must be discussed with the youth minister beforehand.

2.  There will be NO SMOKING during EYC activities and events.

3.  No alcohol, illegal drugs, weapons, fireworks or explosives are allowed.

4.  There will be no sexual misconduct.

 

I agree to the responsibilities assigned to me as an EYC participant.  I realize this is a Christian   organization and I will act accordingly.

  I agree

 

 

PARENT RELEASE

 

Medical Information and Release of Liability:

Please list any conditions your teen has that may be of concern. (Mobility impairments, past serious illnesses, etc.)

 

List any medications your child is presently taking.
Does your teen need assistance with medication?	yes, explain: no
Do adult leaders have permission to dispense Tylenol, aspirin, Pepto-Bismol or other over the counter medications?	YES  NO
Are there any medicines you DO NOT wish your child to take?
Any additional information about participant’s behavior, physical, emotional or mental health or any restrictions on activity.

 

In consideration for my child participating in Cathedral Church of St. Luke, Orlando, Florida, EYC events and activities, we (I), being 21 years of age or older, do for and on behalf of my child participant, if said child is not 21 years of age or older, do hereby release, forever discharge and agree to hold harmless the Cathedral Church of St. Luke, Orlando, Florida, and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in the above described activity. 

 

Furthermore, we (I) and on behalf of our (my) child participant if under the age of 21 years, hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.

 

The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.

 

We (I) are the parents or legal guardian(s) of this participant, and hereby grant our (my) permission for him/her to participate fully in said activities, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment and assume the responsibility of all medical bills, if any. 

 

Hospital Insurance:	YES  NO	Name of Insurance carrier:
Policy Number:		Group Number:
Family Doctor’s Name:		phone number:

 

If participant is under 21, both parents must accept unless parents are separated or divorced, in which case, the custodial parent must accept.

 

Father:			Accept Date:
Mother:			Accept Date:
Legal Guardian:			Accept Date:

   

Any questions please call Anne Taylor at (407)849-0680, ext 215.