Combined Consent and Health Form - 2013
Your signature at the end indicates your consent and acceptance of the provisions included in this document. Name _____________________________________________________________________________ Parish/School _____________________________________City & Province___________________ Age _____________ Gender ________ Home Phone ( ) _____________________________ Mailing Address ____________________________________________________________________ City, Prov & Postal Code_____________________________________________________________ Emergency Contact: Name: ____________________________________ Phone Number: ___________________________ Relationship_______________________________ Name: ____________________________________ Phone Number____________________________ Relationship_______________________________ PARTICIPATION CONSENT : I, (Name of Parent or Guardian) __________________________ grant permission for my son/daughter to participate in the YouthLeader program. LIABILITY WAIVER: I will not hold the Roman Catholic Archiepiscopal Corporation of Winnipeg, the Roman Catholic Archdiocese of Winnipeg, its parishes and schools, the Center for Ministry Development, YouthLeader program administrators and facilitators, parish team leaders, or the program facility responsible in the event of any injury or accident to my son or daughter while participating in the YouthLeaderprogram and/or traveling to and from the program. STATEMENT OF HEALTH: I hereby warrant that, to the best of my knowledge, my child is in good health and able to participate in all program activities. (Please submit a statement indicating limitations and/or conditions of which we should be aware.) INSURANCE INFORMATION Health Insurance Co.: __________________________ Policy No. ___________________________ FAMILY PHYSICIAN INFORMATION Physician or Clinic: ________________________________________Phone ____________________ Physician/Clinic Address_____________________________________________________________ ALLERGIES/DIETARY NEEDS: Please attach a statement noting all known allergies, including how the child has been treated and with what medication. If medications are needed occasionally or regularly, please send them with your child in case of need. If your child has special dietary needs or restrictions, please attach a statement listing these dietary concerns. MEDICATIONS: Any medications brought to the program should be clearly labelled and in their original container. Please list any prescription or approved non-prescription drugs your child is presently taking. Include product name and physician's instructions on dosage and frequency. ____________________________________________________________________________________ ____________________________________________________________________________________
I understand that all prescription medication will remain in the possession of the adult team leader and be dispensed as prescribed. I grant permission for non-prescription medication (such as ibuprofen, Tylenol, throat lozenges, cough syrup) to be given to my child, if deemed advisable. If there are any non-prescription drugs you do not want administered to your child please list them below: _______________________________________________________________________ ____________________________________________________________________________________ OPERATIONS OR SERIOUS INJURIES: (Within the past 18 months) Operation/Injury ___________________________________________Date ____________________ COMMUNICABLE DISEASES: Please notify your YouthLeader Sponsor immediately if your child has been exposed to any communicable disease (mumps, measles, chicken pox, etc.) within three weeks prior to attending the YouthLeaderprogram. MEDICAL EMERGENCY: In case of medical emergency, I understand that a reasonable effort will be made to contact parents or guardian of participants. In the event that I cannot be
reached, I hereby give permission to the physician selected by the Team Leader from the parish/school to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child, as named herein. SIGNATURE OF PARENT OR GUARDIAN: I certify that the above information is correct and give permission for my child to be transported in privately owned vehicles and/or via public transportation for approved YouthLeaderprogram activities; and for the release of medical records to an attending physician in case of illness. I fully understand the consequences of the foregoing statements and sign this form knowingly, freely, and willingly. (Your signature must appear below or your child will not be permitted to participate in theYouthLeaderprogram.) Signature _________________________________________________Date ____________________
USE OF PHOTOS: I hereby grant Roman Catholic Archiepiscopal Corporation of Winnipeg, the Roman Catholic Archdiocese of Winnipeg, its parishes and schools and the Center for Ministry Development permission to use photos or videos of my child taken during program activities, or quotations from my child for future program promotion purposes. Signature_____________________________________________ Date__________________ Code of Behaviour 2013
We are happy and excited that you are joining us as part of YouthLeader2013. The Code of Behaviour has been developed as a way of helping participants understand what is expected of them during the week, and of making the learning experience a healthy and growthful one for all involved. Please read through the Code carefully, as you will be expected to honour and uphold it throughout your time with us.
As necessary as rules are to maintain order, they can't and won't guarantee a successful
YouthLeaderexperience. Success depends on people's willingness to work together for the common good.
Participants take part in YouthLeaderas part of a parish or school team. The adult
leader of each team maintains primary responsibility for the actions of his or her team members. The sponsoring parish or school and the families of team members assume responsibility for any damage done to the facilities.
Participants are expected to attend all sessions unless explicitly excused by the Program
Name badges should be worn during all program activities.
Dress throughout the YouthLeaderexperience is casual, however shirts and shoes must
Socializing should take place only in the designated public areas of the housing facility.
No visiting is allowed in sleeping areas occupied by the opposite sex.
Each day will be a busy one - making adequate sleep a necessity. Participants must be in
their respective rooms by curfew time. The noise level in the sleeping areas should be kept at a minimum. Scheduled quiet and silent times must be honoured. Only the Program Director can alter curfew times or the timing of any other scheduled activity.
Smoking is not allowed during scheduled group activities or in the facility. All other
smoking restrictions must be honoured (ages, locations, times, etc.)
The purchase, possession or consumption of alcohol or drugs by participants will result
in immediate dismissal from the program. Major infractions of the Code of Behaviour will meet with the same consequences.
Parent or Guardian (if participant is not 18 years of age): I agree that my child shall abide by the rules and regulations outlined in the YouthLeader Code of Behaviour. I have reviewed it and discussed the Code with my child prior to signing this form. I agree that if my child fails to consistently abide by the Code or engages in a serious infraction of the Code, he or she may be immediately dismissed from the YouthLeader program and sent home at my expense. Signature __________________________________________ Date ___________________
Youth Participant: I understand and agree to the YouthLeader Code of Behaviour. I also understand that my parent(s) or guardian will be notified at the time of any infractions requiring my dismissal from the program and that I will be sent home at my own or their expense. (Your signature must appear below in order to participate in the YouthLeader program.) Signature _________________________________________ Date ____________________
Jordan F. Karp, MD Bruce Rollman, MD, MPH Debra Weiner, MD Jill A. Tarr, LCSW Principal Investigator Co-Investigator Co-Investigator Project Coordinator ADAPT: ADDRESSING DEPRESSION AND PAIN TOGETHER 2011 Summer What is ADAPT? Funded by the National Institute on Aging for the next 4 years, the ADAPT study will test whether combined treatment with antidepressant medication