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2022-23 Trinity Youth Leader - Medical and Photo Release Form

TRINITY PRESBYTERIAN CHURCH | 3003 HOWELL MILL RD NW | ATLANTA, GA 30327

Trinity Presbyterian Youth Ministry Covenant

FOR ALL PARTICIPATING STUDENTS AND ADULTS

While participating in any Trinity Presbyterian Youth event, trip, or gathering on or off-campus, I will do my best to live together with others as a family in Christian community. I will love, respect, trust, support, and encourage others. I will seek to create and maintain a safe atmosphere that promotes inclusivity and the value of all people.

1. When away from Trinity Presbyterian Church I will recognize that I am a guest to our hosts. And, as a guest, I will be considerate to our hosts and to their leadership team. I will respond to them with gratitude for their hospitality.

2. I agree to abide by all rules laid out by the Trinity Presbyterian Youth Staff, and I will be respectful of the Youth Staff, Youth, all Youth Leaders.

3. As a member of Trinity Presbyterian Youth, I will:

  • Be responsible for my own belongings and respect the property of others.
  • Participate, as I am able, in all activities of the youth ministry trips and events.
  • Be respectful of all adult leaders.
  • Care for and be respectful of the property of Trinity Presbyterian Church, and/or, our hosts.
  • Be appropriate in my expressions of care and concern.
  • Not bring or use any harmful substances or weapons including, but not limited to: weapons of any kind, fireworks, drugs, alcohol, or tobacco products.
  • Treat all people I encounter with love and respect.

4. As a participant in the Youth Ministry of Trinity Presbyterian Church, I agree to abide by this covenant while participating in any Trinity Presbyterian Youth trip, event, or gathering on or off-campus. I understand that breaking this covenant may result in my parents being notified and that I may be asked to go home at my parent's expense. 

Please refer all questions to:

Emily Beaver

Director of Family Ministries

ebeaver@trinityatlanta.org

(828) 772-0302 

Date: March 29, 2024


Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
PARTICIPANT HEALTH INFORMATION

Year of last Tetanus Shot *

Primary Doctor *

Doctor Phone # *

Pertinent Medical History, Known Allergies (especially to foods & medications)

Regular Medication - Description and Schedule

Check here if:

I want you to remind my child to take his/her medication.
I want Trinity youth staff to keep and administer my child's medication.

HEALTH INSURANCE INFORMATION


Insurance Company

Company Phone #

Name of Policy Holder

Group #

Policy #

I agree to travel to and from and to participate in Trinity Presbyterian church trips and activities under Trinity supervision from 01/01/2022 to 12/31/2023. 

In consideration for the privilege of participation in any and all trips or activities, I agree to release and hold harmless Trinity Presbyterian Church, its employees, pastors, directors, volunteers, and agents, from any liability without limitation, including those predicated upon negligence for bodily injuries, including those resulting in death, illnesses, damages to myself, and including the contraction of COVID-19 whether a COVID-19 infection occurs before, during, or after participation in any and all Trinity Youth events.

Trinity Presbyterian Church has put in place preventative measures suggested by the Centers for Disease Control and Federal, State, and Local Government to reduce the spread of COVID-19; however, Trinity Presbyterian Church cannot guarantee that you or your child will not become infected with COVID-19. Further, attending Trinity Presbyterian youth events, programs, or trips could increase your youth's risk and your family's risk of contracting COVID-19. By signing this agreement, I acknowledge the highly contagious nature of COVID-19 and voluntarily assume the risk that my youth, and I along with my family, may be exposed to or infected by COVID-19 by attending Trinity Youth events, programs, or trips, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand the risk of becoming exposed to or infected by COVID-19 at Trinity Youth events, programs, or trips. 

In the event of injury, illness, or medical emergency, I hereby authorize Trinity Presbyterian Church to seek medical, rescue, or evacuation services for the above-named child/dependent with the understanding that I am responsible for any expenses incurred.

I also understand that I am required to provide Trinity Presbyterian Church with updated medical information on my child/dependent should any of his/her medical information change between the date I sign this form and 12/31/2023.

I hereby also grant Trinity Presbyterian Church the right to photograph and film me during any Trinity activities, with the understanding that my pictures or videos may be used in promotional materials or otherwise published in print, digital or web form.

By signing this document, I confirm that I have authority to sign, have read the entire document, and understand that the document waives certain rights of the person signing and the participant.

PLEASE READ CAREFULLY, THIS MEDICAL RELEASE IS A LEGAL DOCUMENT

WHICH INCLUDES A RELEASE OF LIABILITY AND INDEMNIFICATION


Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian Date of Birth*
Parent or Guardian Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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