Mosaic Youth Activity Participation Agreement
Name of sponsoring organization: First Church Pella
Address: 605 Broadway, Pella, IA 50219
Name of sponsor’s coordinator: Mike Melody
Telephone: (630) 781-5140
Description: Mosaic Youth Activity
Date and location: Various

This agreement exists to protect First Church Pella, the host of the activity, and the participants of the activity. This agreement serves as an all-encompassing waiver form for the various activities we will do. All students must have this form completed by a parent/guardian to participate in our regular activities. We're committed to having a fun time, but want to ensure a safe environment and make clear the expectations of all participants.

In consideration for the opportunity to participate in the activities hosted by Mosaic Youth, the Student Ministry of First Church Pella, the Participant and parent/guardian acknowledge and accepts the rules listed below. By agreeing to the stated rules, the Participant and parent/guardian also agree to accept responsibility and appropriate consequences based on the level of offense. Consequences will be judged at the discretion of the participant’s leaders and the sponsor coordinator.

Additionally, by agreeing to this form, the Participant and parent/guardian agree to allow First Church and Mosaic Youth the permission to obtain medical treatment for the Participant in case of emergency when parent/guardian cannot be contacted. Participant and parent/guardian agree to hold the activity host, volunteers, leaders, and sponsor coordinator harmless from any liability to the Participant while engaged in the various activities of Mosaic Youth.
Agreed-upon rules:

• No use of illicit drugs (including marijuana, nicotine, vaping, and tobacco) or alcohol.
• Smoking and the use of tobacco products are not allowed to, from, or during any trip.
• Presence at and full participation in all group activities, including adherence to curfews and other time-related instructions.
• No sexual misconduct (defined as exposure, touching, or inappropriate reference to body areas normally covered by undergarments).
• Must be in assigned rooms by designated time unless for scheduled events.
• Coed visitation only allowed in a public setting.
• Will not break any American laws.
• No physical altercations or verbal fights.
• Use of cellular devices only at times that are deemed appropriate.

My youth have permission to attend and participate in all activities sponsored by First Church – Pella, including some events that may take them off-site. I believe the necessary precautions for the care and supervision of the youth will be taken during the activities hosted by First Church. I (we) will not hold responsible First Church or any of its leaders.
Email *
Grade during 2020/2021 school year
Clear selection
Name of Participant *
Participant Email
Name of Parent/Guardian *
Parent Email
Address *
Phone *
I agree to give Mosaic Youth and its representatives permission to photograph, and record my child for use in digital media.
Clear selection
Youth Participant’s Statement: By checking the box, I agree to the contents of the form described above. *
Parent/Guardian Statement: By checking the box, I agree to represent the Participant I represent, and I agree to the contents of the form described above. *
A copy of your responses will be emailed to the address you provided.
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