AYM Contact Form 23-24

Parent Information
Primary Parent Contact*

First NameLast Name
Primary Parent Email*
example@example.com
Primary Parent Phone Number*
Please enter a valid phone number.
Secondary Parent Contact

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Who would you like to receive communcation?*

primary parent contactsecondary parent contactboth

Emergency Contact Information

This should be someone other than a parent/gaurdian.
Name*

First NameLast Name
Relationship to Teen*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Medical Information
Are there any medical conditions (i.e. allergies, epilepsy, asthma, diabetes, travel sickness, etc.) which we should be aware of?*
Please give any details of special dietary needs we should be aware of (e.g. food allergies)*
Are there any disabilities or special needs we need to know about?
Physician*

First NameLast Name
Physician Phone Number*
Please enter a valid phone number.
Health Insurance Company*
Policy Number*
Do you grant permission to adult chaperones to give my child non-prescription drugs (Tylenol, etc.) in the event circumstances reasonably demonstrate that my child is in need of such drugs?

NO, contact me or get medical help if my child has any minor medical concernsYES, I give permission for an adult youth leader to give my child over-the-counter medications as directed on an as-needed basis to treat non-emergency medical conditions
PARENT SIGNATURE: I hereby authorize any adult chaperone to consent to any medical treatment of the named youth, which, in the judgment of recognized medical facility, under the general or special supervision of a licensed physician, may be deemed necessary, during any AYM event.*

Clear
Medication Permission/ Instruction

Policy for dispensing medication: If your son or daughter will bring medication to any overnight event, please fill out the following parental permission/instruction. This is for all participants under the age of 18.
Is the student on any current medication(s) that the youth minister or other adults should be aware of?
Is your child responsible for taking their own medication?

Yes.No.
If no,please list when each medication is taken along with the appropriate dosage.
If you need an adult to help administer the medicine during any AYM event, please put the medicine in a ziploc bag and label it with your teen's name, to be turned in when you arrive on Friday evening.

Transportation Permissions

Throughout the year, Assumption Youth Ministry travels to various places. From off site retreat centers, to ice cream runs on a random Wednesday, we go to a lot of places! Please choose all that you are comfortable with below. You will be informed whenever we travel somewhere.
I give my teen permission to...*

ride in the car of another adult.ride in the car of another teen.drive themselves and no one else.drive themselves and up to 2 more teens.ride in the Assumption Shuttle bus.ride on a greyhound bus (ex: Steubenville trip).
WAIVER AND RELEASE FOR SERVICES

1. In consideration for providing transportation services and for other good and valuable consideration, I release, discharge and indemnify Assumption Parish-Mattese, its officers, employees, agents and volunteers from all claims, actions, damages, whether known or unknown, past present and future;
2. This waiver and release applies to any negligence, and specifically negligence arising out or the transportation services, including, but not limited to, the operation of the vehicle, while entering and exiting the vehicle and while I am a passenger;
3. I assume the sole responsibility for my own actions and I represent that I have the ability to care for myself and will remain seated during the transport and will secure myself with any safety devices such as seat belts;
4. This waiver and release also applies to any claims, actions and damages caused by other passengers and I will hold harmless and indemnify Assumption Parish-Mattese, its officers, employees, agents and volunteers from such claims or actions.
5. I understand that transportation is being provided to me at my request by a faith community at no charge to me.
6. I have read the terms of this waiver and release and assume all risk and sole responsibility for my own safety and well being.
7. This waiver and release is binding on my agents, heirs and assign.

TEEN DRIVERS & RIDERS

As parent or legal guardian, you remain fully responsible for any legal responsibility which may result from any personal actions taken by the named student.

I hereby consent to participation by my child, named above, in the various events that they register for throughout the year. I understand that these events will take place away from the church/school grounds and that my child will be under the supervision of the designated AYM volunteer(s) on the stated dates. I further consent to the conditions stated above on participation in any AYM event, including the method of transportation.
Parent Signature*

Clear

Media Authorizations
The youth ministry program at Assumption utilizes the following forms of social media and electronic communication: Flocknote, email, Instagram @AYMSTL and @AYMEDGE, Facebook, and the parish website.

For good and valuable consideration, the sufficiency of which is hereby acknowledged, I/we, the undersigned grant the Archdiocese of St. Louis (“Archdiocese”) the right to publish, reproduce and display photographic images, video images and/or audio recordings of (“Child/Teenage Participant”) for use in all media, electronic or otherwise, in connection with publications, advertisements, social media and/or web pages of the Archdiocese. The Archdiocese is not authorized to sell or otherwise distribute such photographic images, video images or audio recordings to any other person or entity without my/our consent. I/We understand that the Archdiocese may associate the photographic image, video image or audio recording with the first name of Individual and the name of the parish or school where Individual is a student or parishioner. I/We further acknowledge and agree that neither I nor Individual, if Individual is a minor, has or shall have any ownership interest in any informational or advertising material which utilizes, incorporates or consists of the photographic images, video images and/or audio recordings or in any copyright embodied therein. I consent for my child to be photographed or recorded on video during the course of youth ministry events and for their image to be used in either print, electronic or video form for the promotional purpose of future activities.
I do.I do not.

Code of Conduct

Please review with your teen and have them sign at the bottom.
Code of Conduct

First and foremost, you are Christian ladies and gentlemen; you are disciples of Jesus Christ, and you are representing your Parish

General Guidelines:
• Always follow the instructions of your chaperones, high school teens, adult leaders, and youth minister.
• Be sure to meet with your small group at the designated times and locations. Do not go anywhere by yourself or without telling one of the leaders.
• Respect others in what you do and say.
• Respect the facility by picking up after yourselves and only using the spaces and supplies provided.
• Dress modestly.
• No “purpling” which would imply no guy and girl physical contact of any kind.
• Electronics only to be used during appropriate times, as designated by the youth minister or core team members.
• Absolutely no illegal drugs, alcohol, weapons or tobacco products of any kind.

I have read and understood the expectations and guidelines for this event and will cooperate with these rules. I understand that failure to comply may result in immediate dismissal, with transportation home by my parents
Teen Signature*

Clear
Should be Empty:

AYM Contact Form

Teen Information

Parent Information

Emergency Contact Information

Medical Information

Medication Permission/ Instruction

Transportation Permissions

Media Authorizations

Code of Conduct