Hope Church Youth Ministry 2015-2016 Youth Participation Packet Effective Dates: September 1, 2015 August 31, 2016 Why we need this form This information helps us keep you informed about what s happening in Hope Church Youth Ministry throughout the year email will be our primary means of communication. Complete medical/emergency information helps us ensure youth safety at all events and filling out this form once means we won t ask for the same information for every event. So if any of your information changes, please notify Hope Church Youth Ministry! YOUTH INFORMATION Name Nickname DOB Gender Grade School: Primary Address: Which guardian(s) lives at the primary address? Secondary Address: Which guardian(s) lives at the secondary address? Youth Email Youth Home Phone Youth Cell Phone OK for leaders to text youth? YES / NO T-shirt size: OPT-IN If you would like your name, address, graduation year, birth date, phone number, and email shared with the LCMS Office of Rosters and Statistics to be used only for Concordia University System recruitment purposes and LCMS Campus Ministry, please initial here: PARENT / GUARDIAN INFORMATION Name(s) Email(s) List all phone numbers where the parents/guardians can be reached (type: i.e. home, work, cell) Page 1 of 6
PARENTAL CONSENT The undersigned does hereby give permission for (youth s name)( Participant ), to attend and participate in any Hope Church Youth Ministry activities, events, retreats, lock-ins, and trips during the period of September 1, 2015 August 31, 2016. LIABILITY RELEASE: In consideration of Hope Church allowing the Participant to participate in Youth Ministry (Sunday worship, Sunday Bible Class, Activities, Events, Retreats, Lock-Ins, Trips, etc.), I, the undersigned, do hereby release, forever discharge and agree to hold harmless Hope Church, its pastors, leaders, teachers, employees, and volunteers (collectively herein the Church ) from any and all liability, claims, or demands for accidental personal injury, sickness, or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in Youth Ministry activities. I, the parent or legal guardian of this Participant, hereby grant my permission for the Participant to participate fully in Youth Ministry activities, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage, and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful, or intentional acts of said Participant, including expenses incurred attendant thereto. MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the Participant has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the Participant 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 or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned youth pursuant to this authorization. TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for the Participant to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by Hope Church. Seat belts will be worn at all times. PHOTO RELEASE: I agree that Hope Church may photograph and record the Participant s likeness and activities during church-related activities. I grant the following rights to Hope Church: permission to use and re-use, publish and re-publish, and modify or alter photos taken of the Participant for Hope Youth Ministry / Hope Church purposes. x Name of youth participant Signature of youth participant Date x Name of parent/guardian Signature of parent/guardian Date Page 2 of 6
MEDICAL INFORMATION YOUTH INFORMATION (Please Print) Youth Full Name Nickname Home Address Home Phone DOB PARENT / GUARDIAN EMERGENCY CONTACT INFORMATION Parent/Guardian Name(s): List all parent/guardian contact phone numbers in best order to be reached: NON-PARENT / NON-GUARDIAN EMERGENCY CONTACTS Contact #1: Relation: Phone(s): Contact #2: Relation: Phone(s): PRIMARY CARE PHYSICIAN Name: Phone(s) Fax: Name of practice: Date of last Tetanus shot (required) INSURANCE INFORMATION Medical Insurance Company: Phone: Policy/Group ID#: Policy Holder s Name (please print): DENTIST Name: Phone(s) Fax: Name of practice: Page 3 of 6
MEDICATION: List all medications the youth will take during any youth ministry trips or events. This includes any prescription or non-prescription medications, herbal supplements, and vitamins. Youth are not permitted to carry any prescription or non-prescription medications but are to give all medications to the adult youth leader in original containers with complete dispensing instructions. Exceptions will be made for epipens, rescue inhalers, and other emergency medication. Medication Name Dose Treatment for Dispensing instructions Example: Zyrtec 5mg Seasonal allergies Take one pill daily in the morning with food OVER-THE-COUNTER MEDICATION PERMISSION: Do you give permission for your youth to be given over-thecounter medication as needed (and as directed on the label) to treat non-emergency medical conditions that do not require a doctor or hospital visit while at a youth ministry event? No, do not dispense any medications. Contact me if my youth has any minor medical concerns. Parent/Guardian Signature Yes. I give permission for an adult youth leader to give my youth the following over-the-counter medications or their generic equivalents (as available) to treat non-emergency medical conditions on an asneeded basis please circle all that apply: Ibuprofen Pepto Bismol Tums/antacid tablets Tylenol Imodium AD Cough drops Benadryl Dramamine Sudafed Parent/Guardian Signature MEDICAL CONDITIONS: Please answer in detail as applicable. Attach additional pages if necessary. 1. List any medical conditions you have (asthma, diabetes, epilepsy, celiac disease, etc.): 2. List any allergies (drug/medicine, food, and/or environmental) and the severity and type of reaction: 3. Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know, for example any special dietary needs or activity restrictions. Page 4 of 6
Hope Church Youth Ministry Covenant of Community Expectations Mission Statement of Hope Lutheran Church Sharing the hope of Jesus with a world in need of hope Mission Statement of Hope Youth To walk with youth, discipling them in faith, life, and mission Purpose of Hope Church Youth Ministry The purpose of Hope Church Youth Ministry is to meet Youth where they are with the redeeming and restoring love of Jesus Christ. We are here to walk with Youth through both the highs and lows of real life. Nurturing faith, equipping and empowering, and partnering together are all found in the context of community centered around our Savior. Hope Church Youth Ministry Values The infallible Word of God leads, and at its center is the Gospel. Youth are a unique part of the Body of Christ, with gifts to serve the Church now, even as they are discovering God s plan and preparation for the future. Safety to ask difficult questions and wrestle with the real-world issues of faith we encounter in our daily lives is necessary for continued development of an owned faith. Stewardship requires equipping and empowering of Youth in their God-given talents and giftedness. We are called to partnership as the Body of Christ. Technology and Music and are gifts from God, not ends in themselves. Speaking the truth in love is an expression of our willingness to bear with one another. We are called to life together, including respect of other opinions and perspectives. Every person matters to God. Every Youth, no matter their background or experience, is welcome. We will affirm the value of every person and walk with them in discovering God s purposes in their life. Families and family relationships are God s design as a place for Youth to grow and develop. We will support parents and Youth together. Behavior Our actions flow from our heart. God calls us to live as His people, and others can be blessed and encouraged by actions that line up with our values. Behavior that hinders the mission, purpose, and values of Hope Youth will not be accepted. All Hope Youth are expected to live under the following Scriptural principles: Hebrews 13:17 Obey your leaders and submit to their authority. Hope Youth are to respect and honor their leaders and their guidance at Hope Youth events. Hope Youth are expected to follow all civil laws, e.g., no illicit use of drugs or alcohol. Hope Youth are to uphold God s laws and will for their lives, e.g., no sexual misconduct. Ephesians 4:3 Make every effort to keep the unity of the Spirit through the bond of peace. Hope Youth are to participate; don t anticipate at all events, by being fully present, and honoring the goals and purposes of the group. Hope Youth are expected to avoid anything that divides or breaks relationship, distracts or tears down, whether inside or outside of Hope Church. Page 5 of 6
Hope Youth are to be respectful of common spaces and property, both here at Hope and elsewhere. Hope Youth are to honor others at all times in their body, property, and reputation. Ephesians 4:29 Do not let any unwholesome talk come out of your mouths, but only what is helpful for building others up according to their needs, that it may benefit those who listen. Hope Youth are to be appropriate in their words, avoiding the use of foul language, cursing, or any speech (including humor ) which puts down, makes fun of, or stereotypes others. Hope Youth are to be respectful, encouraging, and maintain a positive attitude toward others at all times, recognizing Christ s presence in each other. Hope Youth are to be encouraging and to speak the truth in love at all times (Ephesians 4:15). Philippians 2:3 Do nothing out of selfish ambition or vain conceit, but in humility consider others better than yourselves. Hope Youth are to think of the community, continually looking out for the needs of others. Hope Youth are to be respectful of speakers and presenters who are teaching. They are to respect others in discussion and look for ways to encourage understanding and growth. Hope Youth are to use cell phones appropriately, silencing them when requested. Hope Youth are to guard against exclusivity and rather seek to include those who are left out. Hope Youth are not to engage in bullying behaviors (physical, emotional, or spiritual). 1 Timothy 4:12 Don't let anyone look down on you because you are young, but set an example for the believers in speech, in life, in love, in faith and in purity. Hope Youth are to be appropriate in their relationships with others. Public displays of affection don t belong at Hope Youth activities. Hope Youth are to honor God and others in their sending and receiving of text or images, social media posts, and internet usage. Hope Youth are to recognize that others are watching their behavior and that they are called to reflect Christ as they represent the Church. CONSEQUENCES FOR INAPPOPRIATE BEHAVIOR As Hope Youth Leaders, it is our goal to handle problems immediately, consistently, and in a spirit of love and gentleness. Using scripture, we will show students how their behavior is not pleasing to God and is harmful to themselves or the youth group. The leaders will always seek a result that includes confession, forgiveness and restoration. Participant s Statement: I pledge to honor God and respect others by upholding this Covenant of Community Expectations. I understand that if not, my family may be asked to take me home. x Participant s Signature Date Parent/Guardian s Statement: I agree to support this Covenant of Community Expectations and accept all costs and responsibility if it is necessary for my youth to return home due to disciplinary action. x Parent/Guardian s Signature Date Page 6 of 6