Holy Kids Camp Forms for Youth and Families

Forms for Families with Children Participating in Holy Kids Camp
Family Name
Parent 1 Full Name
Parent 2 Full Name
Child 1 Name and Grade (Separate name and grade with a comma)
Child 2 Name and Grade (Separate name and grade with a comma)
Child 3 Name and Grade (Separate name and grade with a comma)
Child 4 Name and Grade (Separate name and grade with a comma)
Child 5 Name and Grade (Separate name and grade with a comma)
I have children in Middle school and/or High school who would like to participate in Ignite events this year. In filling out these forms, I understand that they will also be used for Ignite events.
Participant's Name 1
Birth Date 1

MonthDayYear
Date
Participant's Name 2
Birth Date 2

MonthDayYear
Date
Participant's Name 3
Birth Date 3

MonthDayYear
Date
Participant's Name 4
Birth Date 4

MonthDayYear
Date
Participant's Name 5
Birth Date 5

MonthDayYear
Date
I give permission for my child(ren) (named above) to attend the sessions and service projects associated with Faith Formation and Holy Kids Camp at the Church of St. Mark in St. Paul, Minnesota.

Medical Release: I hereby authorize the Faith Formation and Holy Kids Camp leaders, volunteers, the Church of St Mark, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this and all health care forms and to provide all medical or dental care, routine tests, treatment and necessary transportation advisable for the health and safety of my child.This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision, and upon the advice of or to be rendered by a licensed physician or dentist.

Custody Release: I further authorize the Faith Formation and Holy Kids Camp leaders of the Church of St. Mark in St. Paul,Minnesota to receive physical custody of my child upon completion of any treatment, and I specically instruct any treating health facility to surrender physical custody of my child to said adult.

Activity Release: I further give permission for my child to participate in all activities sponsored by Faith Formation and Holy Kids Camp of the Church of St. Mark in St. Paul, Minnesota, except as noted:
Signature of Parent or Guardian

Clear
Printed Name of Parent or Guardian
Date

MonthDayYear
Date

Emergency Contact Information

Church of St. Mark- Faith Formation and Ignite
Parent/Guardian Names
Street Address
City
State
Zip Code
Parent/Guardian 1 Name
Home and Cell Phone Number (Separate with a comma)
E-Mail Address
Parent/Guardian 2 Name
Home/ Cell Number (Separate with a comma)
E-Mail Address
Other Emergency Contact (1)
Name
Relationship to Participant
Home/ Cell Number (Separate with a comma)
E-mail Address
Other Emergency Contact (2)
Name
Relationship to Participant
Home/ Cell Number (Separate with a comma)
E-mail Address

Health Care Information

Church of St. Mark- Faith Formation and Ignite
Name and Birthday of Participant 1 (Separate with a comma)
Physician Information of Participant 1 (Include Physician's Name, Phone Number, your Insurance Company, Policy/Group Number and name of Policy Holder)
Dentist Information of Participant 1 (Include Dentist's Name, Phone Number, your Insurance Company, Policy/Group Number and name of Policy Holder)
Please Check if the Physician and Dentist Information is the same for all the listed Participants
Name and Birthday of Participant 2 (Separate with a comma)
Physician Information of Participant 2 (Include Physician's Name, Phone Number, your Insurance Company, Policy/Group Number and name of Policy Holder)
Dentist Information of Participant 2 (Include Dentist's Name, Phone Number, your Insurance Company, Policy/Group Number and name of Policy Holder)
Name and Birthday of Participant 3 (Separate with a comma)
Physician Information of Participant 3 (Include Physician's Name, Phone Number, your Insurance Company, Policy/Group Number and name of Policy Holder)
Dentist Information of Participant 3 (Include Dentist's Name, Phone Number, your Insurance Company, Policy/Group Number and name of Policy Holder)
Name and Birthday of Participant 4 (Separate with a comma)
Physician Information of Participant 4 (Include Physician's Name, Phone Number, your Insurance Company, Policy/Group Number and name of Policy Holder)
Dentist Information of Participant 4 (Include Dentist's Name, Phone Number, your Insurance Company, Policy/Group Number and name of Policy Holder)
Name and Birthday of Participant 5 (Separate with a comma)
Physician Information of Participant 5 (Include Physician's Name, Phone Number, your Insurance Company, Policy/Group Number and name of Policy Holder)
Dentist Information of Participant 5 (Include Dentist's Name, Phone Number, your Insurance Company, Policy/Group Number and name of Policy Holder)

Video and Photograph Release Form
The testimony or likeness of participants in events or activities hosted by members of the Church of St. Mark and Pro Ecclesia Sancta (PES), may appear in photographs, videos and other records taken at the event. The Church of St. Mark and PES may wish to use these Images in the production of publicity or informational materials appearing in print publications, fliers, brochures, onthe Internet, or elsewhere. For this reason, and to protect the privacy of the Participants, parents orguardians of all participants under the age of eighteen are asked to sign this Release Form.

Signing this form is entirely voluntary and efforts will be made to minimize the appearance of those participants who have not consented to the use of their likeness in said materials. Photographs, videos, and other records taken during the course of the event or activity remain the property of the Church of St. Mark and PES.

CONSENT AND RELEASE

I authorize the Church of St. Mark and PES representatives to use any photographs, artwork and videos which may contain the names, testimony, likeness or voice of myself and my child/children in the production of audio recordings, photographs, videos and other materials in the Church of St. Mark and PES’s websites, e-mails, brochures and other informational materials without additional consideration to them or me.

I understand that I may revoke this consent at any time in writing delivered to the Coordinator of Faith Formation and Youth Ministry and that such revocation will not affect the use of any images created prior to the receipt of the revocation.

I hereby release, acquit, and discharge the Church of St. Mark, PES, and their representatives and members from any and all claims, arising now and in the future, related to the making, use, or distribution of materials containing the names, testimony, likeness, or voice of myself or my child/children.

I acknowledge that this consent and release is given of my own free will, that I give it withoutthe promise of compensation, and that I have been given an opportunity to read this document and understand its content.
Name and Age of Participant 1 (Separate Name and Age with a Comma)
Name and Age of Participant 2 (Separate Name and Age with a Comma)
Name and Age of Participant 3 (Separate Name and Age with a Comma)
Name and Age of Participant 4 (Separate Name and Age with a Comma)
Name and Age of Participant 5 (Separate Name and Age with a Comma)
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Printed name of Parent/Guardian
Relationship to Participant

DISCLOSURE, AUTHORIZATION AND CONSENT FOR SOCIAL MEDIA OR OTHER ELECTRONIC COMMUNICATION INVOLVING MINORS

Church of St. Mark and Pro Ecclesia Sancta
I am the parent or legal guardian of (full name of minor(s)) ("My Child(ren)"
(List names of Child/ Children separated by a comma)
In order to ensure transparency and parental involvement, the Church of St. Mark has created this consent form so that parents and guardians may provide authorization for the Church of St. Mark and Pro Ecclesia Sancta leaders to electronically communicate with minors. Such communications must comply with applicable Church of St. Mark and Pro Ecclesia Sancta policies, including restrictions on private communications with minors.

I grant permission for staff or other leaders of the Church of St. Mark and Pro Ecclesia Sancta to communicate with My Child electronically. I understand that such communications are for Church of St. Mark and Pro Ecclesia Sancta purposes only and may involve group communications relating to Church of St. Mark and Pro Ecclesia Sancta activities. Further, I understand and authorize that such electronic communications may be made via text, email, telephone and cell phone, social media, digital networking, and other electronic means.

I acknowledge that to review or receive public communications shared via social media with My Child, I will need to have an account with the same social media platforms or become a fan or follower of the same social media. I also understand that communications may be accessible or viewable by others who are also fans or followers of the same social media.

This Disclosure, Authorizations, and Consent form is valid for one year.

If I choose to rescind this authorization and consent, I agree that will inform the Church of St. Mark and Pro Ecclesia Sancta in writing and that this rescission will not take effect until it is received by the Church of St. Mark and Pro Ecclesia Sancta.
I have read the above Disclosure, Authorizations, and Consent, have had the opportunity to consider their terms, and understand them. I execute this document voluntarily and with knowledge of its significance.
Parent/Guardian Name (please print)
Email address
example@example.com
Address
Phone number
Cell number
Child Email address
example@example.com
Child cell number
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
Should be Empty:

Forms for Families with Children Participating in Holy Kids Camp

Emergency Contact Information

Health Care Information

Video and Photograph Release Form

DISCLOSURE, AUTHORIZATION AND CONSENT FOR SOCIAL MEDIA OR OTHER ELECTRONIC COMMUNICATION INVOLVING MINORS