Youth Tubing Trip

Number of people participating

Youth Name(s)

Birth Date(s)

Grade(s)

What church do you attend?

Emergency Contact

Parent/guardian Name

Phone Number

This address will receive a confirmation email

Emergency Contact Name

Relationship to youth

Phone Number

Medical Information

Insurance Company

Insurance Policy Number

Any medical conditions or activity restrictions?

Yes No

If yes, please list.

Any allergies or food restrictions?

Yes No

If yes, please explain.

Medications Currently Taking (a responsible adult will administer medication throughout the day)

Last Tetanus Immunization

Community Covenant for Youth Events

I acknowledge and accept in writing that community life at a youth event is based upon mutual trust, respect for others and adherence to the spirit and to the specifics of a set of standards as follows:
- I will respect all others and their possessions;
- I will treat the staff and property with respect and will treat all buildings and furnishings with care;
- I will not use or possess alcohol, illegal drugs, fireworks, firearms or any other kind of weapon;
- I will not use or possess tobacco in any form;
- I will not ride in or drive a motor vehicle without specific permission from an adult leader;
- I will not participate in any inappropriate sexual behavior;
- I will not alter my appearance in any permanent or semi-permanent manner (i.e., tattooing, piercing, and hair dyeing).
Attending a youth event is a privilege, and participants are encouraged to enter fully and cooperatively into the community life. Church staff reserve the right to terminate participation in the event and to send home at his/her expense any person whose conduct is considered detrimental to the community.

I agree to the covenant above

Yes No

Transportation Permissions

The undersigned does also hereby give permission for my youth to ride in any vehicle driven by an approved adult chaperone while attending and participating in activities sponsored by St. John's, St. Marys, St. Peter's, and The Falls Church Episcopal. My youth and I understand that seat belts must be worn at all times during transportation.

Yes No

Liability Release

I agree by execution of this document to release St. John’s, St. Mary’s, St. Peter’s, and The Falls Church Episcopal, the staff, and all others acting for or on their behalf from all liability whatsoever, for personal injury, or damages to property, real or personal, caused by, or arising out of activities sponsored by the above churches.

Yes No

Payment [$45 per person, max $135 per family]

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Youth Tubing Trip

Description

Please Fix the Following