St. Leo's youth permission / health / code of conduct form

#1 Child's Name *

Full First Name Last Name

#1 Name tag name

first name only

#1 Date of Birth *

Date

#1 gender *

female male

#1 Grade *

#1 Elementary only (chose one)

#1 Place of Baptism (if Baptized): (church name and city, state) *

#1 Place of First Communion (If has had First Communion): (Church name and city, state) *

#2 Child's Name

Full First Name Last Name

#2 Name tag name

first name only

#2 Date of Birth

Date

#2 gender

female male

#2 Grade

#2 Elementary only (chose one)

#2 Place of Baptism (if Baptized): (church name and city, state)

#2 Place of First Communion (If has had First Communion): (Church name and city, state)

#3 Child's Name

Full First Name Last Name

#3 Name tag name

first name only

#3 Date of Birth

Date

#3 gender

female male

#3 Grade

#3 Elementary only (chose one)

#3 Place of Baptism (if Baptized): (church name and city, state)

#3 Place of First Communion (If has had First Communion): (Church name and city, state)

Parent / Guardian #1 name *

First Name Last Name

Parent / Guardian #1 phone *

Area Code Phone Number

Parent / Guardian #2 name

First Name Last Name

Parent / Guardian #2 phone

Area Code Phone Number

Parent / Guardian work phone

Area Code Phone Number

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Name: Alternative Emergency contact if parents not available / permission to pick up your child *

First Name Last Name

Emergency contact phone / permission to pick up your child *

Area Code Phone Number

USE OF PHOTOS: I give St. Leo's Parish Community permission to use photos or videos of my child taken during program activities for St. Leo's promotional and informational purposes on the web page and in the media (Your child's name and identity will not be used during these instances)

Initial if you agree to give permission for use of your child's (children's) photo

(initial)

Permission to share information with Grand Island Diocesan offices:

The Grand Island Diocesan Child Protection Office, the Faith Formation & Evangelization and the Youth and Young Adult Ministry offices have requested the sharing of child name, grade, parent's names and address. The use of this information is so that follow up on safe environment principles can be made with families and also to promote diocesan family and youth programs.

Do you wish to have your child's name, grade, parent's name and address shared with the Grand Island Diocesan offices? *

NO Yes

ALLERGIES: Please list all known allergies, including how the child has been treated and with what medication. (please list child's name if multiple children being registered): *

MEDICAL CONDITIONS: I hereby warrant that, to the best of my knowledge, my child is in good health and able to participate in program activities. Please list all known medical conditions including limitations and/or conditions of which we should be aware of: (please list child's name if multiple children being registered) *

MEDICATIONS: please list all medications child is taking (please list child's name if multiple children being registered): *

Please indicate *

I prefer that she/he be responsible for these Medications her/himself. I prefer that the staff hold these medications and dispense according to the directions.

Every effort will be made to provide a safe environment physically, emotionally and spiritually for your child. Please note any additional information you think the staff and volunteers should have to achieve this goal. This would include mental health issues and family dynamics such as divorce or deaths in the family. This information will be keep confidential and will only be used with staff and volunteers so that we can be sensitive to the needs of your child. (please list child's name if multiple children being registered)

Please indicate: *

I DO give permission for this minor to be given over-the-counter treatments (such as Tylenol, Tums, Sudafed, etc) if she/he experiences discomfort and requests treatment. Parents will be contacted prior to dispensing any over-the-counter treatments. I DO NOT give permission for this minor to be given over-the-counter treatments (such as Tylenol, Tums, Sudafed, etc) if she/he experiences discomfort and requests treatment. Parents will be contacted of any discomfort and requests for over-the-counter treatments.

AUTHORIZATION FOR MEDICAL TREATMENT: I/We, as the parents/legal guardian of the aforementioned minor residing at the above named address, understand that should a medical emergency of my child occur, St. Leo's Parish Community staff and volunteers will make every attempt to contact us.

I/We hereby grant St. Leo's Parish Community, their staff, and volunteers permission to transport this minor to an emergency medical or health care facility for immediate treatment and/or consultation, if deemed necessary. I/We understand that I/we will be notified of any emergency situation immediately and give permission for our child to be transported to a medical facility by ambulance if necessary.

I/We give authorization to the attending physician, dentist, or medical personnel for any required immediate treatment in the event that I/we cannot be reached at the time of the emergency. I/We agree to be financially responsible for any and all medical expenses and/or treatment costs and all related services provided to the above mentioned minor, and I/We release the St. Leo's Parish Community, their staff, and volunteers from any liability.

PERMISSION TO PARTICIPATE / TRANSPORTATION / RESPONSIBILITY FOR DAMAGE:

I/We understand that participation in the activities at St. Leo's Parish Community are sponsored by the St. Leo's Parish Community. I hereby grant permission for MY/OUR son/daughter to participate in the children / youth programs at St. Leo's Parish Community.

This includes being transported by staff and volunteers to and from some activity sites, with prior notification of such off-site activiites by St. Leo's Parish Community staff.

I/We accept full responsibility for any legal or financial consequences which may result from any personal actions (ie. damage to property or other participants/staff/volunteers) taken by MY/OUR son/daughter, and I/WE agree to hold the St. Leo's Parish Community, their staff, and volunteers harmless with respect to any actions or claims that may be made in connection with personal actions taken by MY/OUR son/daughter.

INSURANCE/MEDICAL INFO: If medical attention to my child is deemed necessary during parish activities, I/We authorize the release of information of/to my/our insurance company and family physician:

Insurance Company name

Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Ins. Co. Phone number

Area Code Phone Number

Ins. Co. Policy number

Physician's Name

Physician's address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Physician's phone

Area Code Phone Number

Signature of parent (E-Signature) to consent of your child's/Children's participation in St. Leo's Parish Communities youth programs (valid for one year) *

Clear

Date *

Date

Code of Conduct (parents, please review this code of conduct with your child)
To accomplish the purpose of children / youth minstry programs at St. Leo's Parish Community, everyone must agree to a “Code of Conduct.” These guidelines are necessary to make participation enjoyable for all and to avoid problems. Participants have a responsibility to themselves and others to follow these guidelines:

Be Respectful and Safe. During childrens / youth ministry programs at St. Leo's Parish Community we expect to create an environment of safety and trust. The use of our bodies, language, and humor must always honor the dignity of every person. If you jeopardize the physical or emotional safety of yourself or the group, you choose to have a parent or guardian pick you up and take you home immediately.

Be Responsible and Honest. Participants are expected to be present at all activities on time and participate fully. Established guidelines will be observed at all times. We need to take care of the building and grounds. Any damage is to be reported immediately and involved persons are financially accountable. Emergencies that involve the health and well-being of people and/or property must be reported to staff and volunteers immediately.

The use of illegal drugs, including alcohol, or other illegal/harmful substances is not permitted. If you use these materials, you choose to have a parent or guardian pick you up and take you home immediately. Proper authorities will be notified. Do not bring clothing that advertises/promotes alcohol, tobacco or drug use or anything displaying messages that are offensive or contain sexual innuendo. These are contrary to the values of a Catholic children / youth ministry program.

Observe appropriate boundaries. All participants must stay in designated areas. Vehicles can only be used with specific permission from the director. For overnight retreats, males and females are lodged in areas with separate rooms. Participants do not enter each other’s rooms unless supervised by an adult. One of our goals is to relate with everyone present. If you engage in activities contrary to these guidelines or any activities that jeopardize your safety or the safety of the group, you choose to be removed from the activities. Your parent or guardian will be called to pick you up and take you home immediately.

Dress Code

In order to promote a safe, healthy and positive community experience the following dress code must be followed by all male and female participants and staff members. Shirts must be long enough to naturally touch the top of the lower garment, with arms raised.  Shirts must cover the shoulders. All attire should be sized to fit without exposing undergarments, buttocks, stomachs or cleavage.
 
Shorts and skirts must be fingertip length when arms are resting at sides
 
No Spaghetti straps, tank tops, and halter tops or transparent/mesh clothing or shirts with revealing necklines or armholes
 
No clothing or accessories that promote drugs, alcohol or tobacco either by brand or message
 
No clothing or accessories with sexually suggestive language or messages or clothing or accessories that promote violence, criminal activity, intimidation or intolerance of others (based on religion, ethnicity, gender or lifestyle)
 
Modest swim suit appropriate for a Catholic children's and youth's retreat setting.

Parent / Participant Signature:

I/We understand and accept the guidelines and policies stated in this Code of Conduct. I will accept the consequences should my son/daughter choose to violate the code. I agree to come and pick up my son/daughter, should he/she choose to behave in a manner that the director and staff judge to be a serious violation of this code and is contrary to the mission of St. Leo's Parish Community.

Parent / Guardian signature, I have reviewed the Code of Conduct with my child (children): *

Clear

Child participant signature, I (we) have reviewed the code of conduct:

Clear

Child participant signature, I (we) have reviewed the code of conduct:

Clear

Child participant signature, I (we) have reviewed the code of conduct:

Clear

Date *

Date