Youth MDPC Release Form 2017-2018

Please fill in the fields below with the youth's name along with the preferred contact email, cell phone and home address.

*Address Line 1
Address Line 2
*Zip/Postal Code
Indemnity and General Release

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Memorial Drive Presbyterian Church (hereinafter “MDPC”) and its staff of any liability against personal losses of named youth.  I the undersigned have legal custody of the youth named and have given my consent for him/her to attend events being organized by MDPC.  I understand that my electronic signature below carries with it the following:

I am aware that activities may include participation in sporting/recreational events.  (Note: if you desire to limit your youth’s participation in any event, please submit your wishes in writing to the MDPC Executive Pastor prior to that event.)

I give permission for the named youth to be transported to and/or from church-sponsored events and church-approved meetings by:  A) church provided transportation (cars, vans, buses, planes) and/or B) adult driven transportation (MDPC Youth Staff, adult volunteers).

I am aware that the MDPC Youth Staff and Volunteers have completed Child Protection Training, a criminal background check and personal reference check prior to their involvement with youths.  MDPC invites into ministry only those adults who a) have no previous convictions for sexual or physical abuse of children; b) for whom they receive positive responses from their references; and c) who meet MDPC's qualifications and ministry standards of the position for which they are applying.

I am aware that the MDPC Youth Staff and Volunteers contact youths outside of church activities for ministry purposes through text message and social media. If I am uncomfortable with this contact, I will contact Laura Miller in the Youth Office to discuss this further.

In the event that the named youth is injured, or should require medical or dental attention while participating in a church-sponsored event, I hereby authorize the church representatives or sponsors of the event to secure necessary medical treatment for the named youth and 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.  I further understand that it is solely my responsibility to notify the MDPC Youth Ministry of any changes regarding the named youth's health, medical insurance, or guardianship information.  I do hereby specifically release, waive, discharge, and covenant not to sue MDPC, its staff, volunteers, agents, and governing bodies, for any action or causes of action, including, but not limited to, personal injury, property damage, or wrongful death, which may exist or which may hereafter arise during and following the participation of the named youth in a church-sponsored event occurring between the dates listed on this form.  I further understand and agree that in the event that the named youth is involved in activities that violate or compromise the rules, policies, or purposes of MDPC, I will accept full responsibility for release of the named youth to my custody and care.  I further understand that I will cover all financial costs if the named youth is sent home for disciplinary reasons. 

I give permission for any videos or photographs taken of the named youth to be used by MDPC.  No names will be used.

I have completed the contact information, insurance information and the medical history information.  My youth and I have read the above rules of conduct and understand the expectations and consequences. 

"I/We verify that I have read and understand the indemnity and General Release above and below and that all information I have provided is true and correct. Unless terminated in writing, this release shall be effective August 01,2017 through August 31, 2018 only.  " (Please so indicate by checking the box below.)

*Full Name of Parent/Guardian Agreeing to Terms/Conditions:
*Parent 1: First & Last Name:
*Parent 1: Cell #:
Parent 2: First & Last Name:
Parent 2: Cell #:
*Emergency Contact Name (if parent cannot be reached):
*Emergency Contact Phone #:
*Participant's Date of Birth:
*School attending 2017-2018:
*Grade in School 2017-2018:
*T-shirt size:
Medical Information
(if self insured, state so below)
*Medical Insurance Company:
*Insurance Co. Phone #:
*Name of Insured:
*Policy #:
*Group #:
*Rx ID#:
*Rx Group #:
Medical History
Please list and explain any health problems or chronic medical conditions. (physical and/or psychological ailment, illness, weakness, limitation or condition to which the child is subject and of which the staff should be made aware, and what, if any, action of protection is required on account thereof.)
Please list and explain any major illnesses the youth experienced during the pat year.
Please list any medications taken regularly
Please list any known allergies
Please explain if this youth's activities should be restricted for any reason
*Date of last tetanus shot
*Participant's Physician:
*Physician's Phone #:
*Participant's Dentist:
*Dentist's Phone #:
Memorial Drive Presbyterian Church expects each person to conform to these rules of conduct:
- No cell phones, electronic devices all on retreats or mission trips
- No youth can drive without proper authorization
- No possession or use of alcohol, drugs, tobacco or pornography
- No fighting, weapons, fireworks, lighters, explosives, etc.
- No offensive or immodest clothing
- No boys in girls' sleeping quarters and vice versa
- Participation with the group is expected
- Respect property, one another, staff and adult leaders
- Respect and comply with event schedules
A youth who fails to comply with these expectations may be sent home at his or her parent's expense. (So, is it really worth it for them to have their cell phone?)
Internal Use Only: