Participant Name *

First Name

Last Name

Participant Date of Birth *

MM

DD

YYYY

Participant Sex *

Female

Male

Participant Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Participant Phone *

(###)

###

####

Parent/Guardian Name 1 *

First Name

Last Name

Parent/Guardian Name 2

If none, state "None"

First Name

Last Name

Phone 1 *

(###)

###

####

Phone 2

(###)

###

####

Phone 3

(###)

###

####

Non-Parental Emergency Contact *

First Name

Last Name

Non-Parental Emergency Phone *

(###)

###

####

Physician's Name *

Please notify the event staff is this participant has BEEN EXPOSED TO ANY COMMUNICABLE DISEASE within the three weeks prior to this event. Participants will NOT be allowed to attend if they arrive at the event ill.

First Name

Last Name

Physician's Phone *

(###)

###

####

I hereby ________ permission for Christ Church to use pictures of my child within Christ Church, the Diocese and internal communications. *

Grant

Do not grant

EARLY RETURN HOME POLICY: Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility. *

I agree

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT (21+) chaperone in accordance with Safeguarding God's Children policies while attending and participating in activities sponsored by Christ Church. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation. *

I agree

CONTRABAND: Nowhere and at no time during youth events shall youth possess or use firearms, illicit drugs and/or paraphernalia (including lighters), alcohol, or tobacco. *

I agree

QUARTERS: Never shall a male enter a female's quarters or a female enter a male's quarters. We at Christ Church like for everyone to have a good time, and this is part of that: we protect our children. Boys=Blue, Girls=Pink, No Purpling! There will also be cause for disciplinary action if youth are caught in intimate relations, even if not in quarters. This is a mandatory parent notification. *

I agree

CONFIDENTIALITY: All of the details and information of this agreement are confidential and shall only be used by Christ Church and Diocesan Staff (the latter for Diocesan events only). Your completion of this form is the legal equivalent of your signature that you have read and understand all of the information provided and consent to your selections. *

I agree

Digital Signers Name *

This must be the parent/guardian listed earlier in the document.

First Name

Last Name