Youth Ministry Permission Form 2018-2019
Greetings! We are excited in your interested in youth ministry at Epiphany Catholic Church, we may grow in our discipleship God calls us to, together! Please complete this permission form for your youth, this is required for all youth ministry functions, including retreats, service projects, social activities, and youth nights. If you have questions, please feel free to contact Tasha Gordon at 245-9733 ex. 19, or tasha@epiphanycatholicchurch.org
Participant's Name: *
Your answer
Date of Birth
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Age *
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Grade *
School
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Mother/Guardian's Name *
Your answer
Father/Guardian's Name
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Address *
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City *
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State *
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Zipcode *
Your answer
Primary Phone Number *
Your answer
Secondary Phone Number
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Work Phone Number
Your answer
Work Phone Number (if applicable)
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Youth's Phone Number
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Relation to Youth *
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Emergency Contact Phone Number *
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Name of Insurance Company
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Policy Number
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Please list any allergies or special medical problems your child may have: *
Your answer
Date of Last Tetanus Shot:
Your answer
I grant permission for my child to participate in ALL youth ministry activities from June 2018-July 2019, sponsored by the Epiphany Catholic Church Youth Ministry Program (914 Old Harrods Creek Road, Louisville, KY 40223). *
I understand in the event of an emergency, I authorize an adult, in who care the minor has been entrusted to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor to the general or special supervision and on the advice or any licensed physician or licensed dentist on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. *
The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for my child to return home due to medical reasons or otherwise, the undersigned shall assume responsibility for transportation and.or incurred transportation costs. *
The undersigned does also hereby give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by the Epiphany Catholic Church Youth Ministry Program. I will not hold the Archdiocese of Louisville, Epiphany Catholic Church, youth minister, or chaperones associated with the event responsible in the event of injury. *
I give permission to administer over the counter medication (Tylenol, cold medicine, etc.) *
Required
I give permission for my child to have their picture/video taken and posted on Epiphany's website. *
I give permission for my child to have their picture/video taken and posted on an Epiphany bulletin board. *
I give permission for my child to have their picture/video taken and use in publication. *
By checking the box below, you are electronically signing and agreeing to the terms for your child participating in the Epiphany Catholic Church Youth Program. *
Required
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