OPTIONAL MEDICAL INFORMATION. Medication my child is taking at present: Family Health Plan carrier number: Family Doctor: Phone Number: As Parent or Guardian, I agree to all of the above stated considerations and conditions. Signature: Date: MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.)
OPTIONAL MEDICAL INFORMATION. Medication my child is taking at present Health conditions my child has **If you have specific health concerns about your child, please speak to Xxxxxx 2739 STI N S O N BOUL E VAR D NOR T HE AS T ¿ ST . ANT HONY ¿ MIN N E S O T A ¿ 55418
OPTIONAL MEDICAL INFORMATION. Medication my child is taking at present Other Medical Conditions Family Health Plan carrier number Family Doctor Phone Number As Parent or Guardian, I agree to all of the above stated considerations and conditions.
OPTIONAL MEDICAL INFORMATION. Medication my child is taking at present: Allergies: Other Medical Conditions: Family Health Plan carrier name and number: Family Doctor: Phone Number: As Parent or Guardian, I agree to all of the above stated considerations and conditions: Signature: Date: Contact Alyssa (Youth Minister) at xxxxxx.xxxxxx@xxxxxxxxxx.xxx or 000-000-0000 with any questions. Additional disclosure: CHURCH OF ST. XXXXXXXXXX DISCLOSURE, AUTHORIZATION, CONSENT AND RELEASE FOR SOCIAL MEDIA OR OTHER ELECTRONIC COMMUNICATION INVOLVING MINORS I am the parent or legal guardian of (full name of minor) (“My Child”). I certify that My Child is at least 11 years old. I have been made aware of the Church of St. Wenceslaus Acceptable Use Policy for Electronic Communications and the Social Media Policy of Church of St. Wenceslaus. I authorize staff or other leaders of Church of St. Wenceslaus staff to communicate with My Child electronically, including via social media, text, email and phone in accordance with the Acceptable Use Policy for Electronic Communications. Church Personnel are not required to share non-private communications, such as those sent to youth groups regarding meeting locations or times, or other administrative matters. If any staff or other leaders knowingly communicate privately with a minor as a part of his or her duties for or on behalf of Church of St. Wenceslaus reasonable steps must be taken to send to me the same communication content, not necessarily via the same technology. I acknowledge that to review or receive public communications shared via social media with My Child, I will need to become a fan or follower of the same social media. I understand that communications may be accessible or viewable by others who are also fans or followers of the same social media. AUTHORIZATION, CONSENT AND RELEASE FOR USE OF VISUAL LIKENESSES AND ORIGINAL WORKS OF MINORS I authorize and consent that Church of St. Wenceslaus and the Archdiocese of Saint Xxxx and Minneapolis be permitted to use and publish for general communications, advertising, commercial or publicity purposes, or for any other lawful purpose whatsoever the likeness of My Child and My Child’s original work, including video, photographic portraits, pictures, or reproductions, made through any medium, including social or other electronic media, in accordance with the Acceptable Use Policy for Electronic Communications and the Social Media Policy, provided only the first name (not the family name) is identified i...
OPTIONAL MEDICAL INFORMATION. Medication my child is taking at present Family Health Plan carrier number Family Doctor Phone Number As Parent or Guardian, I agree to all of the above stated considerations and conditions. Signature Date CODE OF CONDUCT The following are a few rules that all participants are expected to follow while participating and representing Church of St. Raphael in this event sponsored by Church of St. Raphael on the following dates: Nov. 2, 2019 / Jan. 4, 2020 / Feb. 1, 2020 / Mar. 7, 2020 / Apr. 4, 2020 / May 2, 2020 Please read and sign. I, , WILL: Printed Name of Youth Participant ▪ Treat all other persons with respect and not cause any intentional harm (physically, emotionally, or spiritually) to any person in any way. ▪ Respect the property of others, including all program facilities and property. ▪ Follow all appropriate instructions of all personnel aiding in this event, including, but not limited to, chaperones, support staff, transportation personnel and administration. ▪ Be on time for all check-ins and departure time. ▪ Not have in my possession any tobacco, alcohol or any controlled illegal substance I agree that if any of these terms are violated, Church of St. Raphael can send the participant home at the participant/guardian’s expense. Youth Participant Signature Date Parent/Guardian Signature Date Please return this form to the St. Raphael Youth Ministry Office
OPTIONAL MEDICAL INFORMATION. Medication my child is taking at present _____________________________________ Allergies ______________________________________________________________________ Other Medical Conditions_________________________________________________________ Family Health Plan carrier number _________________________________________________ Family Doctor __________________________________ Phone Number __________________
