List any medications which your daughter/son has in her/his possession at this event.

Can your young person take responsibility for her/his medication or would you prefer that it be given with adult supervision (in which case, supply all necessary instructions from your physician)?

Please list any allergies or other physical or health conditions of which we should be aware.

Are there any first aid ministrations such as aspirin or antibiotic ointment we should avoid using?

In case of medical emergency, I/we understand that every effort will be made to contact the parent or guardian. In event I/we cannot be reached, I/we hearby give permission to the dentist or physician designated by the adult leader(s) to hospitalize, secure proper treatment and/or to order an injection, anesthesia, or necessary surgery.I/We give permission to engage in all activities connected with this event, including transportation to and from the site. I/We hearby indemnify and agree to hold harmless St. Michaels Episcopal Church, it’s members and employees for any and all past, present, or future loss to property, and/or bodily injury resulting from any such activities engaged.

Printed Name(s)_____________________________________________________

Address_______________________________________________________________________________________

Telephone Home_____________________Work______________________Cell/Beeper_____________________

Medical Insurance Company________________________________________________

Medical Insurance ID #________________________Group #___________________

Other person to contact (as alternative means of reaching you in case of emergency)

Name_________________________________Relationship to participant__________________________________

Address________________________________________________________________________________________

I give permission for______________________________to participate in October Weekend

start and end dates/times October 12, 5:00 pm until October 14, 3:00 pm _____________________________________________________________Date_________________

I, the undersigned, being a participant in an activity of St. Michael’s EYC, do hearby contract with the other

participants and adult leaders of this event to abide by the following requirements of Christian community life, and I take upon myself the responsibility for living in accordance with them and helping others to do so.

1. The use of alcohol, tobacco, illegal drugs, firearms, fireworks, and other weapons is strictly prohibited.

2. Inappropriate sexual contact and activity, including pairing off alone, is not permitted.

3. Coed visitation in sleeping areas without an adult present is not permitted.

4. Music played during travel and while at the event will be appropriate for Christians to listen to. Personal earphones are discouraged, as they isolate members of the community.

5. Curfew is determined by the adult leader(s). Curfew is understood to be the time all persons are to be in their assigned sleeping areas with lights and electronic devices off.

6. Full participation in all activities and meals is required unless excused by an adult leader under special circumstances. Each member of the community is expected to be on time.

7. We agree to love one another and treat each other in our words and actions as Jesus would do.

I have read, understand, and agree to abide by the above standards. Failure to sign these standards or live by them may be cause for dismissal from the event.

Participant signature_________________________________________________Date_______________