EYC Registration Form 2020 -2021

Welcome to Holy Trinity EYC (Episcopal Youth Community). We are exciting to have you onboard!

Please take a moment to carefully review and complete this registration form with your child. E-signatures of both parent and youth are required.

This form must be on file for your youth to attend EYC events.

Youth Name *

First Name Middle Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Mobile Number *

Area Code Phone Number

*Please Note If your youth does not have their own phone please put zeros for phone digits. Ex. 000-000-0000.

Youth Email *

example@example.com

*Please Note If your child does not have email type in N/A

Name of School *

Age *

Grade *

Birth Date *

Month Day Year

Parent Name (Parent A) *

First Name Last Name

Mobile Number *

Area Code Phone Number

Email *

example@example.com

Parent Name (Parent B)

First Name Last Name

Mobile Number

Area Code Phone Number

Email

example@example.com

Emergency Contact (Other than Parent A & B) *

Emergency Contact Mobile Number *

Insurance Company *

Policy Holder & Policy Number *

Youth Allergies

Allergy Devices

Epipens, Inhalers, etc.

Severe allergies that require emergency devices must be provided by the parent. Make sure that an advisor is aware of your child's allergy. Your child will need to be in charge of bringing their emergency device, as well as remembering to bring it home. Dinner is served during normal EYC meetings at 6:30pm. If you child has allergies to certain foods, please pack a meal.

Youth Medications

ADD Medication, Seizure Medication, etc.

Youth will need to take their medications before attending EYC Meetings. Special circumstances (offcampus events, weekend retreats, etc.) can be arranged with the youth director prior to the event.

Medical History - Medical Conditions/Disabilities

Personal History - Social/Emotional Conditions

Are immunizations up to date? If not, all immunizations must be updated. *

Yes No

First Aid: Can we administer First Aid when necessary and administer over the counter medications as needed? *

Yes No

EYC is a place of love, friendship and respect. It is a save space where members can be themselves. We expect all youth to conduct themselves with kindness, inclusion of all memebers, and respect for other people, their property and the property of the EYC building.

Mobile phones are permitted, but must be put away when requested by youth leaders.

I promise to be tobacco, alcohol and drug free at all Holy Trinity Episcopal Youth Community activities. I promise to follow the directions and rules of the Youth Minister, mentors, sponsors and volunteers. If I fail to follow this covenant I may be sent home immediately. If this occurs at an off campus it will be at my parent(s) expense.

Youth E Signature *

Clear

Consent of Transportation

I give my child permission to be transported by the provided transportation and legal driver (25 years old and older) as part of his/her participation in the Holy Trinity Episcopal Church Youth Ministry, by whatever means of transportation the Youth Minister and those acting on his/her behalf deems appropriate. I have read and understand the transportation guidelines.

Consent of Release of Liability

I do hereby waive, release, covenant not to sue and forever discharge, to the fullest extent permitted by law, Holy Trinity Episcopal Church and its related or connected organizations, officers, agents, employees, representatives, successors, assigns and all others of and from any and all responsibilities, claims, and expenses, personal injury, wrongful death or liability for injuries or damages of any kind resulting from the participation of my child in any activities of the Holy Trinity Episcopal Church Youth Ministry facilities, rented or owned, or arising out of any Holy Trinity Episcopal Church Youth Ministry activities. I do also hereby indemnify, release and hold harmless, to the fullest extent provided by law, all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury, damage or death to my child, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my child’s participation in any activities of the Holy Trinity Episcopal Church Youth Ministry.

Consent of Medical Release

As a parent and/or guardian, I hereby authorize and direct the treatment by a qualified and licensed medical doctor of my child in the event of a medical or dental emergency which, in the opinion of the attending physician, may endanger his or her life, or cause disfigurement, physical impairment, or undue discomfort if delayed. The authority is granted only after a reasonable effort has been made to reach me.

Consent of Release of Medical Conditions

My child is subject to the afore mentioned allergies and/or medical conditions. I authorize Holy Trinity Episcopal Church to disclose such allergies or medical conditions to a licensed medical doctor in the event my child should require emergency medical or dental care.

General Media Release

I consent to and allow any use of or reproduction by Holy Trinity Episcopal Church of any photographs, videos, or quotes taken of me during any church sponsored events. I give Holy Trinity Episcopal Church the right and permission to use and edit, as needed, my photograph, likeness, voice, or quotations in publications or websites that promotes the mission of the organization.

Parent E-Signature *

Clear

Date

EYC Registration Form 2020-2021

Youth Information

Parent Information

Medical Information

Youth Covenant

Parental Consent