Medical Release & Code of Conduct

First Name *

Last Name *

Date of Birth *

Age *

School Grade *

School Name

Home Address

Parent/Guardians Name *

Parent/Guardian Mobile Phone *

Parent/Guardians E-mail *

Covenant of Conduct

I agree to participate fully in all activities of Pointe of Grace’s Lutheran Church CYFM events that I attend. I agree to respect all other participants, chaperones, drivers and any other persons involved in the events. I will not abuse anyone verbally or physically. I agree to respect my own body by not possessing or using any alcohol, drugs or tobacco. I agree not to bring or possess any weapons of any kind. I agree to remember that I represent the congregation of Pointe of Grace Lutheran Church, and all Christians with my actions. Should I break this covenant, I agree to accept the consequences determined by the chaperones or youth leaders. If it is determined that my behavior warrants my leaving this event, travel to my home or other costs will be at my own expense or that of my parents or guardians.

Participant agrees to follow the Covenant *

Yes

Date: *

Photo Release

I give permission for photos of my student to be taken during church events which may be used for publicity (Facebook, newsletter, church website, etc.) *

Yes

Parent/Guardian Name *

Date *

Emergency Medical Release

I understand that in the event of an emergency, or if any medical or surgical care becomes necessary for the child named above, every attempt will be made to contact me. If I am unavailable, I grant those in charge of the event, permission to administer first aid and to authorize medical attention as recommended by a licensed physician. I agree to pay all medical costs involved in such emergency treatment. I release and discharge Pointe of Grace’s Lutheran Church and/or its representatives involved in this event from any liability whatsoever in exercising this permission.

Parent/Guardian Signed Agreement *

Date *

Other Important Information

Physician's Name *

Physician's Phone Number *

Insurance Company Name *

Policy Number *

Emergency Contact Name *

Emergency Contact Phone Number *

Any Known Allergies, including all drug allergies and special medical conditions or needs. *

Yes

List Allergies or medical conditions

Date of last tetanus shot *