Youth Ministry Covenant
Please provide the information below which Pastor Caitlan will keep on record. Please complete one for each child in your family.
Child's Name *
Your answer
Child's Grade (Entering Fall 2018) *
Your answer
Child's Birthdate *
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DD
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Parent/Guardian Name(s) *
Your answer
Mailing Address *
Your answer
Parent/Guardian Phone Number(s) *
Your answer
Parent/Guardian Email(s) *
Your answer
Insurance Provider and Policy Number *
Your answer
PCP Name and Phone Number *
Your answer
Please list any health concerns, medications, allergies, etc. Pastor Caitlan should be aware of. *
Your answer
I give permission for my child to participate in all activities planned by PCC Youth Ministry. I support Caitlan and the adult leaders chaperoning these activities, and I give them permission to take reasonable action, as they deem necessary, to protect the best interest of my child. *
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases PCC and its staff of any liability against personal losses. I, the undersigned, willingly allow my son/daughter to participate in events/programs organized by PCC Youth Ministry. In the event that he/she is injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that I 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 affirm that the health insurance information provided above is accurate and active for any care my child may require. *
I do/do not give my permission for PCC to use my child’s picture on their website, social media sites, and for media releases (web & print) in which to advertise a church event. *
The following is a statement of conduct for all youth activities (events, bible studies, trips, etc). I agree to abide by the following code of conduct during all youth activities (events, bible studies, trips, etc). I WILL RESPECT EVERYONE: I will respect, listen to, and cooperate with all youth leaders, chaperones, drivers, and any other adult at all times. I will respect and strive to build up each person in our youth group, visitors, and others. I will not bully, gossip, harass, intimidate, demean, prank, physically attack, verbally abuse, threaten (verbal or written), make jokes or innuendos about ANY person at ANY time. Bullying will NOT be tolerated under any circumstances. I will listen when others are speaking, as I want to be listened to in the same manner. I will not disrupt teaching times, small group times, etc, with pranks, goofing around, or other obscene behavior. I WILL RESPECT PROPERTY: I will respect all property that belongs and does not belong to me. I will not steal, destroy, or hide things that do not belong to me. I will not sit on tables, play rough with games, and be rough on furniture in the youth room. I will help clean up any trash left in the youth room – especially my own. I will not be rough, destroy, or trash up any other space used outside of the youth area. This includes other parts of PCC and places we are guests. I WILL RESPECT MYSELF: I will refrain from all improper behavior, including using illegal drugs and alcohol. (Note: All medication will be handled and distributed by an adult leader.) I will refrain from using profanity – this includes racial slurs and derogatory comments. I will not bring weapons to any youth group activities. I will not bring harm to myself, or others. I will not leave the supervisory presence of adult leaders without prior permission from them – i.e. leaving youth meetings, leaving church grounds, leaving the group during trips, etc. I will dress modestly during all youth activities. If I do not, I understand that I will be given appropriate clothing to borrow during said activity. I WILL HONOR CHRIST: I will reflect a Christian attitude in all my personal relationships during all youth activities, as well as in public. Public Displays of Affection (PDA) are NOT permitted during any youth activity (events, bible studies, trips, etc). This includes but not limited to kissing, forms of cuddling, and any action sexual in nature. This goes for all students and leaders who are NOT married. I will reflect a Christian attitude every place I go, knowing that I am a light for Christ. Failure to comply with this covenant results in one or more of the following actions: Meeting between student(s), parent(s), and Caitlan. Being sent home from said activity at Parent/Guardian expense. Being dismissed from next youth activity – time determined between Caitlan, Youth Leaders, and Parent/Guardian *
Your electronic signature below indicates that you agree to the above covenant. This should be signed by a parent/guardian and the youth. *
Your answer
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