Clarksville Cumberland Presbyterian Church

Youth Ministries

Summer 2017- Spring 2018

Policies & Procedures/Health History & Consent to Treatment

1410 Golf Club Lane

Clarksville, TN 37040

Youth Ministries Conduct Policies

1. Adult and Youth participants will respect each person and all property.

2. Youth participants shall listen to and cooperate with all adult sponsors, chaperones, or drivers.

3. The pyramid of leadership during youth events, trips, etc. will be as follows:

(A) Youth Leader/ Church Staff

(B) Adult Chaperones/Sponsors

(C) Youth

4. Adult and Youth participants will meet all check-in and departure times during any event or

on any trip.

5. Granted any time to divide the group (theme parks, malls, etc. excluding camps) we will follow the following guidelines:

  • Middle school age youth must remain with an adult in their group of a ratio of at least 3 youth to 1 adult
  • High school age youth may split up in a group that may be no less than 3 people. This may include youth of a different church who are at the event.
  • Middle schoolers who join with high schoolers must have and adult present with group
  • At multi-church events youth of middle school age may join with another church group for free time as long as the leader agrees to stay with the youth and has appropriate contact for CCPC leaders.
  • Group “splitting” is at the discretion of the youth leader or lead volunteers.

6. Adult and Youth participants will attend all devotional/group meetings as requested during any

event or on any trip.

7. Adult and Youth participants will abstain from the consumption of alcohol, tobacco or any illegal

drugs. Intentional misuse of prescription or over-the-counter medications will not be permitted.

8. Adult and Youth participants will abstain from using any profane or explicit language, listening

to music with profane or explicit lyrics, or wearing inappropriate or revealing clothing, including

clothing with profane language or alcohol/tobacco/drug logos. If any article of clothing is in

question of being appropriate, the final decision will be made by the Youth Leader or Church

Staff.

Swimwear will not include the following: bikinis, thongs, or speedos. Tankinis are

acceptable, unless prohibited by specific programs or events.

9. Adult and Youth participants will not carry or possess dangerous weapons at any church event

or on any church-sponsored trip.

10. Wear a seat belt when riding in vehicles for any church event.

11. Conduct yourself in a Christ-like manner during all activities.

12. During overnight trips, no boys will be allowed in girls’ rooms or girls in boys’ rooms without

adult supervision. While we encourage healthy relationships between boys and girls, no overly

affectionate behavior will be tolerated on church trips.

The Program Leader (or Church Staff) reserves the right to send home person(s) who are intentionally oppositional or repeatedly refuse to follow the directives mentioned above for any church event or trip. The parents will be called immediately and expected to make arrangements for the return of their child. Any costs incurred (including but not limited to airfare, bus, taxi, etc.) to return the child is the sole responsibility of the parent/guardian.

Limits on Minors as Drivers or Passengers

1. Minors may not drive from any one point to any other point during a church event. In the event of needing to make a late arrival, youth must be driven by a parent or guardian unless arrangement is made between a parent and leader. In the event that a minor drives themselves to an event, they may not transport any other youth unless clear consent has been given by the parent.

Policy concerning media resources

All media resources used for pleasure or fellowship purposes (i.e. movies on the bus or at lock-ins, etc.) will be rated G or PG only for all ages or may be PG-13 if all present are of or above the suggested age to watch the film. Any media resources that are suggested to be used as teaching tools and require parental consent will be addressed individually and will require written permission for each spectator that is under the suggested age to view the film.

Child’s Full Name______

Child’s Date of Birth______Current grade in school______

Social Security #______

Parent(s) or Legal Guardian(s)______

Residential Address______(Street Address)

Apartment #______

City______State_____ Zip______-______

Parental Emergency Contact Information

Father’s home phone______

Father’s cell phone______

Father’s work phone______

Other means of contact for emergency use______

Mother’s home phone______

Mother’s cell phone______

Mother’s work phone______

Other means of contact for emergency use______

Please note that should your child require emergency care that renders him/her unable to participate in the programs/events/ministries of Clarksville Cumberland Presbyterian Church (including in-state and out-of-state mission trips, choir tours, etc.) a parent or legal guardian will be responsible for retrieving the child and providing transportation home.

Child’s Health History

Please check all that apply and give approximate date of diagnosis, if applicable.

check Date

___ Hay Fever ______Bed Wetting ______

___ Ivy Poisoning______Ear Infection ______

___ Recent Insect Sting ______Heart Defect/Disease ______

___ Penicillin ______Bleeding Disorder ______

___ Fainting ______Sleep Walking ______

___ Chicken Pox ______Mental Retardation ______

___ Measles ______Learning Disability ______

___ Mumps ______Behavioral/Emotional Problems ______

___ Asthma ______Other ______

___ Diabetes ______

___ Seizure ______

Date of last Tetanus Shot______

List Operations or serious injuries (including date)

______

Chronic or recurring illness

______

List any allergies to foods

______

List any food restrictions

______

List any allergies to prescribed drugs or over-the-counter medications

______

List any activities that need to be monitored

______

List any activities that need to be avoided

______

Describe any behavioral or emotional problem your child has

______

______

List any medications that may be required for

Lock-Ins, Mission Trips, Retreats etc. (overnight or longer)

Name of MedicationDosageReason for Taking

1.

2.

3.

Do you give permission for your child to self-administer the above-mentioned medications during the duration of the event/trip? ______YES ______NO

Do you give permission to CCP staff/chaperones to administer Tylenol, Ibuprofen, laxative, or other minor medication as may seem necessary? ______YES ______NO

Physician/Medical Professional Information

Name of Primary Care Physician/Pediatrician ______

Telephone # ______

Name of Dentist ______

Telephone # ______

Name of Psychologist or Psychiatrist (if applicable)______

Telephone # ______

Child’s Health Insurance Information

Insurance Company ______

Telephone # ______

Policy/ID # ______

Group # ______

With my signature I acknowledge that I have read the Policies and Procedures of Clarksville Cumberland Presbyterian Church Youth Ministry and agree to carefully abide by their directives.

Signature of Youth Ministry Participant______

Signature of Parent/Legal Guardian______

I understand that all reasonable safety precautions will be taken at all times by Clarksville Cumberland Presbyterian staff and trip chaperones. I have completed the information in this form to the best of my knowledge. In giving permission for my child to participate in the ministries of Clarksville Cumberland Presbyterian Church, I release Clarksville Cumberland Presbyterian Church, chaperones, and church staff from liability for damages, losses, disease, or injuries incurred by my child.

I understand that I, or the emergency contact listed on this form will be contacted in the case of an emergency. In the case of a health emergency, I hearby give permission and consent to the hospital and/or physician selected by the church staff or chaperones to order X-rays, routine tests, and treatment for the health of my child while said child is under the care, custody, and control of Clarksville Cumberland Presbyterian Church.

PARENT/LEGAL GUARDIAN SIGNATURE______

Clarksville Cumberland PresbyterianChurch has my permission to photograph my child for church promotional purposes, including posting on the church website. At no time will a child be identified in said pictures by name, address, or other identifying information unless prior written permission is granted by a parent or legal guardian.

PARENT/LEGAL GUARDIAN SIGNATURE______

Witness my hand on this ______day of ______in the year______.

Print Name of the Notary Public______

Signature of Notary Public______

Official Seal of the Notary Public: