2018 State Youth Conference Registration

Medical release form/ Code of behavior agreement for

Activate Student Ministries for Faith Community Church trips, events, activities and meetings

Also, registration for State Youth Convention 2018 

How much:

 $200 includes registration and lodging.  Lunch and dinner meals will not be covered in cost. Students should bring money for lunch and dinner meals.

Trip Leaders:

Alex Finney Kayla Finney

 

Demographic
Name of Student
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Parent/Guardian Names
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Student date of birth //
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Address
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Main phone --
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Secondary phone --
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E-mail
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E-mail
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Emergency Contact info
Emergency Contact
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Relation to student
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Primary phone --
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Secondary phone --
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Insurance
Insurance Policy Carrier
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Policy Number or ID
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Group number
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Name on insurnace
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Medical Info
Family Doctor
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Where is the doctor's office located?
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Phone number of doctor's office --
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Any physical limitations we need to be aware of?
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Any allergies we need to be aware of?
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Does the student take any regular medication
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Medication
Message Please complete section if the student takes prescription medication for any reason or if they take over the counter medication on a regular basis
Name of Medication / Dose / When to take
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Name of Medication / Dose / When to take
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Name of Medication / Dose / When to take
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Name of Medication / Dose / When to take
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Emergencies
I understand than in the event that medical intervention is needed immediately every attempt will made to contact the persons listed above on this form. In the event none of these persons can be reached in an emergency situation, I hereby give my permission to the physician selected by the activity leader to hospitalize, secure medical treatment and/or order injection(s), anesthesia, or surgery for my child as deemed necessary. I understand that my insurance for my child will be used as primary coverage in the event that medical intervention is needed. Coverage by Faith Community Church, through it’s accident policy, will be used to back-up what my insurance does not cover. I understand all reasonable safety precautions will be taken at all times by Faith Community Church and it’s agents during all trips, events, activities, and meetings. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Faith Community Church, its leaders, employees, or volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.
Digital Signature: Please enter your full legal name
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Today's Date //
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Expectations
Rules of behavior/code of conduct expected from each student:
- No alcohol, drugs, firearms, or weapons are to be brought, purchased, used, or possessed during any trip, event, activity, or meeting.
- Listen to and respect all leaders at all times.
- Additional expectation for specific events will come with adapted rules for that event

Parent and student behavior agreement
We (parent/guardian and student) have reviewed the code of conduct for all Faith Community Church/Activate Student ministry trips, events, activities, and meetings and agree to abide by them. We also acknowledge that if the subject of this release has to return home because of discipline problems, it will be at the parents/guardians expense (meaning parent/guardian will come get them wherever they are at)
Parent/Guardian Digital Signature: Please enter your full legal name
  •  
Today's Date //
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Parent/Guardian Digital Signature: Please enter your full legal name
  •  
Today's Date //
  •  
Student Digital Signature: Please enter your full legal name
  •  
Today's Date //
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Media Release
We consent to any videos, images, or audio recordings that may be taken of the subject of this release form during trips, events, activities, and meetings to be used responsibly for productions (ie – promo and memory videos) or be posted on the ministries social media (Ministry leader DO NOT use Snapchat) .
Parent/Guardian Digital Signature: Please enter your full legal name
  •  
Today's Date //
  •  
Student Digital Signature: Please enter your full legal name
  •  
Today's Date //
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