CONNECT Youth Group Forms

CONNECT Ecumenical Youth Group 2024-2025

Full Name of Youth(Required)

Preferred Name

Preferred Pronouns

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Current Grade(Required)

Age of Youth(Required)

Youth's Birthdate(Required)

Youth's Email

Youth's Cell Phone Number

May we text you?

Which "CONNECT" Church are you participating with?(Required)

If your "home" church is not part of the CONNECT Youth Group, and you are coming with a friend, please choose the name of your friends church.

If Other, name of CONNECT Church

Parent/Guardian Name(s)(Required)

Parent/Guardian Phone Number(s)(Required)

May we text you?(Required)

Parent/Guardian Email(s)(Required)

Emergency Contact Name(s)(Required)

Relation(Required)

Emergency Contact Phone Number(s)(Required)

Do you have medical insurance?(Required)

Name of Policy Holder:

Relation:

Policy Holder Phone Number:

Insurance Company/ Plan Name

Insurance Company Phone Number

Insurance Company Policy Number

Group Name

Allergies

Dietary Restrictions

Medical Conditions we should know about

Does allergy require an EpiPen?

Date of last tetanus shot

Name of Physician

Phone

Dentist/Orthodontist

Phone

Prescription or regular medication needed at any youth group events, lock -ins, etc.?(Required)

Who will dispense meds listed above? (If applicable)(Required)

Please list below each medication by name, dose, and frequency

Medication

Dose

Frequency

Comments

Date Written

Bactine (topical) for minor wound care, first aid as needed(Required)

Triple Antibiotic Ointment (topical) for wound healing(Required)

Tylenol (oral) as directed on bottle for age/weight(Required)

Ibuprofen (oral) as directed on bottle for age/weight(Required)

Chloraseptic Spray for sore throat as needed(Required)

Cough Drops for coughing, minor throat irritation as needed(Required)

Antacid Tablet (oral) for stomach discomfort(Required)

Miralax (oral) laxative as directed by bottle for age/weight(Required)

Benadryl (oral) for swelling, hives, allergic reaction as directed on bottle for age/weight(Required)

Loratidine (oral) for seasonal allergy symptoms, as directed on bottle for age/weight(Required)

Calamine Lotion or Cortaid (topical) for insect bites/bee stings(Required)

Visine/Murine Plus Eye Drops (topical in eye) for minor eye irritation(Required)

Sunscreen(Required)

Insect/Bug Repellent(Required)

Other (please describe)(Required)

Permission & Signature (2024-2025 Youth Ministry Year)(Required)

PARTICIPATION
1. Give permission for the youth on this form to participate in all youth group activities of the CONNECT Ecumenical Youth Group and/or activities of any of its participating churches. I understand that my child will be involved in programming on the campuses of CONNECT churches, as well as mission opportunities, retreats, and fellowship outings at other sites. I have spoken with my child, and they agree to show respect to the adult leaders, other youth, themselves, and the property of others.
PHOTOGRAPHY/VIDEO/SOCIAL MEDIA
2. Give the CONNECT Ecumenical Youth Group and/or its participating churches permission to use now or in the future, without limitation, or obligation, any and all media, including photographs, film footage, or tape recordings, which may include my child’s image or voice for the purpose of ministry, art, advertising, education, or promotion of the CONNECT ecumenical youth group and/or its participating churches and release the CONNECT Ecumenical Youth Group and its participating churches from any claim or liability to that use. I understand that if I give notice to the CONNECT Ecumenical Youth Group and/or any of its participating churches that I object to a picture or video being used publicly, that it will be removed as soon as possible.
TRANSPORTATION
3. Give my permission for my child to ride in any vehicle with a pastor, youth director, and/or adult youth leader of the CONNECT Ecumenical Youth Group.
SAFETY
4. Give permission, as necessary, for the pastors, youth directors, and/or adult youth leaders of the CONNECT Ecumenical Youth Group and/or its participating churches to search my child’s belongings when the health, well-being, or safety of my child or others requires it.
MEDICAL
5. Hold harmless the CONNECT Ecumenical Youth Group and its participating churches, employees, and volunteers from all claims alleging bodily injury or property damage occurring while the participant is at a CONNECT Ecumenical Youth Group activity or a youth activity of one of its participating churches. 6. Give the pastors, youth directors, and/or adult youth leaders permission to provide over the counter medications following the dosage and directions on medical container, and as indicated on the form above. 7. Give the pastors, youth directors, and/or adult youth leaders permission to provide medications brought to events and lock-ins by parent/guardian or prescribed by a physician while in attendance. 8. Give permission to the pastors, youth directors, and/or adult youth leaders to transport my child to the local hospital for emergency services, if necessary. I understand that all effort will be made to reach me before any medical procedure is performed, unless it endangers my child’s life, causes disfigurement, physical impairment, or undue discomfort should treatment be delayed. If I cannot be reached in an emergency, as the parent and/or legal guardian, I authorize the treatment of my child by the qualified and licensed medical professionals/physicians and give permission to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child. In addition, the pastors, youth directors, and/or adult youth leaders have permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the pastors, youth directors, and/or adult youth leaders about my child’s health status. 9. I understand the information on this form will be shared on a "need to know" basis with the CONNECT Ecumenical Youth Group leadership, which includes pastors, youth directors, other church staff, and adult youth leaders. 10. I give permission to photocopy this form.

I agree to the following

Signature of Parent/Guardian(Required)

Printed Name of Parent/Guardian and Date(Required)

Signature of Youth Participant(Required)

Printed Youth Participant Name, Grade, and Date(Required)

Signature of Parent/Guardian(Required)

Printed Name of Parent/Guardian and Date(Required)

You can find the SPC Child Safety and Policy HERE.

Signature of Parent/Guardian(Required)

Printed Name of Parent/Guardian and Date(Required)