Alive 2009 Middle High Conference Medical Form and Conference Covenant

alive 2009 – UP! Middle School Conference
Parental Consent--Medical Treatment Form


Name of Church:
Bethany United Methodist Church
Youth Leader: Del Heiney






I, the undersigned parent or guardian of (name of teen/child) ________________________________, a minor, do
hereby authorize adult workers with the youth of the above named church to consent to any examination, x-ray,
anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any
physician or surgeon licensed under the provisions of the Medical Practice Act 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.
Further, as parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter
may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity
of first notifying me, and do further agree to hold blameless any physician, hospital or other medical center for
rendering such services.

(Please print the following information)

Child/Participant:




Parent(s) or Guardian:







first

last






Insurance Company or Group:




Policy Number:





Home Address:


______
City:


State:

Zip:
______

Emergency Phone ___________________________ Ask for _________________________

Daytime Phone:




Evening Phone:






Email______________@____________________

Medication/Allergies ___________________________________________________________

Permission to receive OTC Medicine (Tylenol, TUMS, etc.): Yes____ No____

Medical History _______________________________________________________________

Any behavior issues or concerns about your child __________________________________________

I hereby give permission for my teen/preteen to participate in the ALIVE 2009 Middle School Conference. I give
permission for my child to be transported in vehicles operated by the adults in whose care the minor has been
entrusted while attending and participating in the ALIVE 2009 Middle School Conference.
I release and hold harmless Bethany United Methodist Church, its paid and volunteer staff, adult chaperons,
drivers, or students connected with the event or activity from any and all liability for any accident, harm or negative
impact that may occur to my teen as a result of participation in this event.

____________________________________ ______________________
Signature of Parent or Guardian




Date

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alive 2009 – UP! Middle School Conference
Conference Covenant

This Covenant is to inform both the student and the parent of the rules and regulations set forth by
the Alive Conference and Bethany Church Youth Ministries. These rules are to be followed at all times during
the course of this event. If the student breaks these rules their parent or guardian may be asked to pick them
up and take them home from the conference. The decision to send a student home from the conference will
be at the Youth Director’s discretion. As a general rule, the use or possession of drugs, alcohol, or weapons
will result in immediate removal from the event.



• All students must attend the sessions. No one is to be left in the hotel.
• Students may only ride with their assigned driver. No exceptions.
• Students must be under adult supervision at all times, except when in hotel rooms after
curfew.
• Students may not go anywhere by themselves.
• No girls in boys’ rooms and no boys in girls’ rooms. No exceptions.
• Misuse of hotel facilities will not be tolerated. This includes trashing the room, ordering food
to the room, being unnecessarily loud, climbing on balcony, throwing things from balcony,
being disrespectful to hotel staff, making phone calls from room phone, etc.
• If you break it you bought it.
• Wristbands must be worn at all times.
• Students must ask an adult before using hotel facilities (pool, game room, etc.).



Student: I, __________________, understand the above mentioned rules and agree to abide by them. I also
know and am willing to accept the consequences should I choose not to abide by these rules.

Signature: ________________________ Date: / /09

Parent: I, ___________________, understand the above mentioned rules and agree to pick up my child at the
conference at my cost should they need to be removed as a result of disregarding the above mentioned rules.

Signature: _________________________ Date: / /09

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