2026 Diocesan Youth Events - Youth Information Form

2026 Diocesan Youth Events - Youth Information Form

Please contact Heather Campbell, Diocesan Youth Minister, at heather@indydio.org if you have any questions or concerns about this form, your responses, or any other information about your participant.
Participant's Full Legal Name*

First NameLast Name
Participant's Preferred Name (if applicable)
She/her/hersHe/him/hisTheythem/theirsOther
Birth Date*

MonthDayYear
Date
Grade level during the 2026-2027 School Year. *
Home Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Full name of primary adult we should be in communication with:*
Telephone Number of primary adult*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address of primary adult*
example@example.com
Full name of secondary adult we should be in communication with (optional):
Telephone Number of second adult
Please enter a valid phone number.Format: (000) 000-0000.
Email Address of second adult
example@example.com
Name of Emergency Contact*

First NameLast Name
Emergency Contact Telephone Number*
Please enter a valid phone number.Format: (000) 000-0000.
WAIVER OF LIABILITY
I give permission for my minor child/ward (hereinafter “Youth”) to participate in 2024 Diocesan Participant Events (each an “Event”).

I freely give this Release to the Episcopal Diocese of Indianapolis (“IndyDio”), any parishes or other organizations running the Event, as well as each of their respective subsidiaries, affiliates, officers, wardens, agents, employees, staff, sponsors, legal representatives, administrators, assigns, heirs, executors, those for whom IndyDio is acting and those acting with IndyDio’s authority and permission (collectively as “Releasees”), in consideration for my Youth being permitted to participate in the Event.

RELEASE OF ALL CLAIMS. On behalf of myself and my Youth, I hereby release and discharge Releasees from all present and future liabilities, debts, obligations, costs, expenses, damages, losses, charges, judgments, executions, liens, claims, demands, actions or causes of action of whatever nature or description, in equity or at law, whether caused in whole or in part by the Releasees or any other person or thing at the Event while my Youth is present, which I or my Youth and each of our family, estate, heirs, representatives, executors, administrators, successors or assigns (collectively, "Related Parties") may have, whether known or unknown, suspected, asserted or not asserted, arising out of participation by my Youth in the Event (collectively, “Claims”), and agree that Releasees are not responsible for any of the foregoing arising out of the Event, even if caused by their own negligence. I understand, acknowledge, and accept that this Release and Waiver of Liability is intended to be binding on me and my Youth and anyone related to my Youth.

RISKS ACCEPTED. I further understand, acknowledge, and accept that participation in the Event involves certain inherent risks, including, but not limited to, property damage, economic loss, infection by communicable disease, and serious bodily injury (including death), and agree that my Youth is voluntarily participating in the Event and I have full knowledge of the risks involved and accept all risks of participation.

I agree that should my Youth need medical or dental treatment or need to be transported home for any reason, I shall be liable and agree to pay all costs and expenses incurred in connection with such transportation, medical, and dental services for my Youth.
Name of Signing Parent/Guardian*

First NameLast Name
Signature*
Date*

MonthDayYear
Date
Participant Medical Information

Please complete the following questions to assure that we have the most up-to-date information to care for your participant in this activity.
Medical Insurance Company*
Name of Insured on Policy*
Policy Number/Group Number*
Insurer Telephone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Does the participant have any special considerations that we should be aware of? This includes the use of an IEP, 504, special accommodations, medical needs, etc. Please be as descriptive as possible, so that we can provide similar care on this trip that the participant might experience at home or at school. Our staff will follow up if we have any questions on how to best include your participant.
Any dietary restrictions?
Any environmental allergies to be aware of?
Please list all medications participant is currently taking.
CONSENT TO MEDICAL AND DENTAL TREATMENT

I hereby authorize the Staff and Volunteers at this Event into whose care my minor child has been entrusted, to consent to emergency medical or dental care, or both for my child. The authority granted by this authorization includes the authority to consent to an emergency x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child. Strong efforts are to be made to contact parents before undertaking anesthesia or emergency surgery.I further authorize the Staff and Volunteers for this Event to receive physical custody of my child upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to the Staff and Volunteers of the Event.It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required, but it is given to provide authority and power on the part of the Staff and Volunteers in the exercise of their best judgment on what is advisable for my child’s care, upon advice of such physician, dentist, and surgeon.
Signature*
Date*

MonthDayYear
Date
Additional Consents
YesNo
YesNo
Signature*
Date*

MonthDayYear
Date
DIOCESAN YOUTH COMMUNITY COVENANT

Please read the agreement below. It commits your Youth to the rules of the Diocesan Youth Community and makes them subject to logical consequences should they choose not to live up to this agreement, including and up to removal from the described activity for failure to comply. All costs for transportation home will be your responsibility.
ALL PERSONS ATTENDING WILL …
1. Participate fully in all community activities (work details, worship, small group times, workshops, plenary sessions, meals, and all other activities).
2. Comply with the quiet time and lights out time.
3. Respect and care for all of the facilities that are being used.
4. Respect the dignity and feelings of all persons at this event.
5. Respect the property of all persons at this event.
6. Not possess or use tobacco products (diocesan participant events are tobacco-free), alcohol, illegal controlled substances, weapons, or fireworks.
7. Not engage in sexual activity.
8. Not leave the group without notification and permission of an adult supervisor.
9. Keep conversations “episc-appropriate,” meaning appropriate for settings with multiple ages and backgrounds.
10. Commit to being fully present for the event. While technology is certainly allowed, we request that it is put away in your bag or pocket, including listening to music on headphones, during any community activities. Technology is only allowed during free time, unless otherwise dictated.
I have gone over this covenant with my youth.*
Date*

MonthDayYear
Date
Should be Empty:

2026 Diocesan Youth Events - Youth Information Form

WAIVER OF LIABILITY

Participant Medical Information

CONSENT TO MEDICAL AND DENTAL TREATMENT

Additional Consents

DIOCESAN YOUTH COMMUNITY COVENANT