Immaculate Conception Church Youth Ministry Permission Slip

June 2017 – June 2018

Immaculate Conception Church Youth Ministry Permission Slip

I, ______parent/guardian request that my child ______be allowed to participate in Immaculate Conception’s Youth Ministry Program. This Medical Release Form will be kept on file for all Youth Ministry events from June 2017to June 2018.

I further give my permission for my child (children) to ride in any vehicle designated by the adult in whose care my child (children) has been entrusted while participating in the above activities.

In consideration of permitting my child to attend and/or participate, I do hereby, for myself and my child (children) waive and release any and all claims that I might have against Kathy Williams, Director of Youth Ministry, Father Anthony Chandler, Pastor, or any employee or volunteer of Immaculate Conception, the institution of Immaculate Conception, the Archdiocese of Louisville and any designated driver of a van, bus, car, or other vehicle, for any and all injuries or losses suffered by said child (children) whileengaged in the above activities.

Youth Ministry Rules and Guidelines

1. I will respect the right of each person to participate and have fun.
2. I will conduct myself in a responsible manner. I will use age-appropriate language.No cursing. No purple (kissing, holding hands, public displays of affection, etc.)! No risk-taking or dangerous activities!
3. I will be drug free (this includes alcohol and tobacco).
4. I will be respectful to, and cooperate with, all adults who are present.
5. I will remain in the youth building or the other chosen area or facility until the event is over.
6. I will be responsible for any guest I bring and will inform him/her of the Youth Ministry rules.
7. I will be responsible for my own belongings (phones, clothing, etc.)
8. I will dress appropriately. Girls: No short shorts, no revealing or low cut tops, Guys: no shirts with the sides cut out, etc.
   If you are in doubt about a clothing choice, do not wear it! If you follow the OC school dress code, you will be fine.
9. I will follow additional rules tailored for each specific event.
10. I will help clean up at the designated time.

FAILURE TO COMPLY WITH THESE RULES MEANS IMMEDIATE DISMISSAL FROM THE YOUTH MINISTRY FUNCTION. ** YOUTH VIOLATING RULES WILL BE SENT HOME, AND IF WE ARE OUT OF TOWN, IT WILL BE AT THE PARENTS’ EXPENSE. THE STUDENT WILL NOT BE PERMITTED TO RETURN UNTIL THE MATTER HAS BEEN RESOLVED WITH THE DIRECTOR OF YOUTH MINISTRY, THE YOUTH AND THE PARENT OF THE YOUTH.

NO YOUTH WILL BE ALLOWED TO ATTEND ANY YOUTH MINISTRY FUNCTION WITHOUT THIS SIGNED PERMISSION SLIP AND ANNUAL MEDICAL RELEASE FORM (SEE BACK OF THIS FORM).

I AGREE TO COMPLY WITH THE ABOVE RULES AND GUIDELINES.

Youth Signature ______Date ______

Parent/Guardian Signature ______Date ______

Address______home phone______

City______State______Zip______

School ______Grade ______Birth date (mm/dd/yr) ______

Email (Youth/Parent) ______Youth’s cell phone______

Permission to send youth group updates to youth on cell phone via text messages:______Yes ______No

Permission to photograph youth and use photos on social media and parish website:______Yes ______No

Parent(s) Name(s) ______

Please Return this form to:Director of Youth Ministry

Immaculate Conception Church

502 N. Fifth Street

LaGrange, KY 40031

(502) 222-0255 ****FILL OUT BACK

ANNUAL MEDICAL RELEASE FORM

Name______Age______Birth Date______

(Youth)

Parent(s) business phones – Mother (______)______Father (______)______

Parent(s) cell phones – Mother (______)______Father (______)______

Date of most recent physical examination: ______

Family Physician or Clinic ______Phone Number ______

Mark the following allergies with a “Yes” or “No”

Penicillin ______Sulfa ______MSG ______

Poison Ivy______Poison Oak ______Bee Sting______

Wasps/Hornets ______Nuts ______Other______

Indicate if your Child has a history of the following:

Fainting______Headaches ______Convulsions ______

Please indicate any medicines your child is taking (prescription or otherwise):______

______

The undersigned does hereby give permission for my/our youth ______. (Name of youth)

to attend and participate in activities sponsored by Immaculate Conception Church during ______. (Year)

We (I) authorize Kathy Williams or any designated adult, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned youth pursuant to this authorization.

Should it be necessary for my/our youth to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

Medical consent forms will be used only as needed. Every effort will be made to first notify the parent or guardian prior to the use of the medical release form.