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: