St. Matthew's Youth Information, Consent & Standards Form

In order for youth to participate in youth ministry or youth music ministry activities or trips, all parts of this form must be completed and reviewed by all parents/legal guardians and youth.

Youth Information

Last Name *

First Name *

Middle Name

Preferred Name/Nickname (if different from first name)

Grade *

Age *

Date of Birth (mm/dd/yyyy) *

School *

Cell Phone # (if none, please write none) *

I can receive texts (please answer yes or no with a short explanation if needed) *

Email address *

Street Address Line 1 *

Street Address Line 2

City *

State *

Zip Code *

Parent/Guardian Information

Legal Guardian 1 - relationship to youth (mother, father, grandfather, etc.) *

Legal Guardian 1 First Name *

Legal Guardian 1 Last Name *

Guardian 1 Primary Phone # *

Guardian Secondary Phone #

Guardian 1 Email Address *

Legal Guardian 2 - relationship to youth

Legal Guardian 2 First Name

Legal Guardian 2 Last Name

Guardian 2 Primary Phone #

Guardian 2 Secondary Phone #

Guardian 2 Email Address

Medical/ Insurance/ Emergency Information

***PLEASE GIVE US A COPY OF BOTH THE FRONT AND BACK OF YOUR YOUTH'S MEDICAL INSURANCE CARD***

Medical Insurance Company Name (if none, please write none) *

Insurance Group #/Policy # (if none, please write none) *

Insurance Billing Address (if none, please write none) *

Emergency Contact Name *

Emergency Contact Relationship to Youth *

Emergency Contact Phone # *

Youth's Primary Physician Name (if none, please write none) *

Youth's Primary Physician Contact # (if none, please write none) *

Please list all of your youth's allergies or medical conditions as well as any additional medical information that is needed (if none, please write none) *

Please list (and describe if necessary) all of your youth's medications and/or reactions to medications (if none, please write none) *

Please describe any illness or condition which the ministry team or a treating physician should be aware, and what, if any, limitation for activity or action of protection is required (if none, please write none) *

Consent

Consent for Participation: I/We the undersigned have legal custody of the youth named above, a minor, and have given our consent for him/her to attend and participate in all youth events and or youth music events organized by St. Matthew's United Methodist Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss or damage to person or property that may occur during the course of my/our child's involvement.

By typing my full name in the following field I acknowledge that I have read, understand and agree to the Consent for Participation statement listed above *

Consent for Transportation: I/We give permission for the above named youth to be transported during St. Matthew's youth events. Transportation may be by Church van, private vehicle, or other conveyance. I understand that there will be supervision for each trip and that all passengers will be required to comply with travel rules set by the church. I also understand that the Church provides no insurance or transportation other than standard liability insurance coverage. I/We are responsible for transportation to and from any event, and this may be done by youth licensed to drive with my/our permission. I/We also agree to bring my/our youth home at my/our own expense should they become ill or if deemed necessary by a youth or music ministry team member.

By typing my full name in the following field I acknowledge that I have read, understand and agree to the Consent for Transportation statement listed above *

Consent for Medical Treatment: In the event that the youth named above is injured and requires the attention of a doctor, I/we consent to the rendering of routine or emergency medical/dental care necessary to preserve the health of my/our youth, including diagnostic, medical and surgical treatment by authorized members of a outpatient, emergency or hospital staff or their designees, as may in their professional judgment be necessary. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided is accurate at this date and will, to the best of my/our knowledge, still be in force for the youth named above. I also authorize first aid to be administered as judged to be needed by ministry staff.

By typing my full name in the following field I acknowledge that I have read, understand and agree to the Consent for Medical Treatment statement listed above *

Consent for Photography: I/We give permission for photographs or video of the aforementioned youth to be taken during St. Matthew's youth events. These images may be used in publications, multimedia presentations, on the church website, social media pages, or to store for the purposes of archiving. Any and all images/videos posted online will not identify the youth by name and will not be used for commercial purposes.

By typing my full name in the following field I acknowledge that I have read, understand and agree to the Consent for Photography statement listed above *

St. Matthew's Youth Community Standards

As a ministry of St. Matthew's UMC, we expect each youth and adult to meet these community standards. Details and policies for these standards are found in the SMUMC Youth Community Standards document.

We will be respectful and welcoming to all youths and adults.
We will follow leader instructions and event schedules.
We will fully participate with the group activities.
Note: Early youth departures require permission by a leader.
We will respect all property at church or other event locations.
We will respect personal property of other individuals participating in youth events.
We will stay within the designated buildings/areas assigned to our group.
We shall refrain from:

abusive, malicious, or offensive language
possession or use of alcohol, drugs or tobacco, including e-cigarettes/vapes/etc.
fighting, weapons or anything that might be perceived as a weapon, fireworks, lighters, or explosives
offensive or immodest clothing
public displays of affection, sexual misconduct, or harassment

Adults are to drive during ministry events as detailed in the SMUMC Child/Youth Protection Policy.
Males will not enter female sleeping quarters and females will not enter male sleeping quarters.
During designated free time, Sr. High youth will be in groups of at least three, and Jr. High youth will be with leaders.
Use of mobile phones, computers, or media players is at the discretion of leaders. Any device brought is the responsibility of the owner.
Some events and trips require previous participation and demonstrated observance of community standards.

Any youth who does not act in accordance with these expectations may be sent home at their guardians' expense, and limits or other conditions may be placed by ministry leadership on future participation. Youth and their guardian(s) will also be responsible for any property loss or damage they have caused.

I/We have provided the above information, have read and consent to my/our youth's participation, transportation, medical care and photography. I/We have also read and agree to the St. Matthew's Youth Community Standards. I/We understand that this consent will apply to all situations present and future, and that a copy of this form is as valid as the original. This consent is to remain in effect for one year from the date submitted or written revocation is made. By entering my full name below I confirm that I have shared and discussed all of the information included on this form with my/our youth as well as all other legal guardians.

Parent/Guardian 1 Full Name: *

Today's Date: *

Parent/Guardian 2 Full Name:

Today's Date:

Youth's Full Name: *

Today's Date: *