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Microsoft word - 2014 waivers

2014 Fort Creek Baptist Church Youth Waiver
for Medical Treatment and Participation in Activities
(Youth) Name: _______________________________________________ Name Called _______________________________
Address ________________________________________________________________________________________________
City: _____________________________________ State: __________________ Zip __________________________________
Date of Birth:_______________________ Age ________ Sex: M_____ F_____ 2013-2014 School Grade___________
Youth Home Phone Number __________________________
Youth Cell Number _________________________________
Parent/Guardian Names __________________________________________________________________________________
Home Phone: ___________________________ Cell(s): __________________________________________________________
Another Person To Call ___________________________________________________________________________________
Home Phone: __________________________ Cell: _________________________ Work ______________________________
Medications Taken Regularly ______________________________________________________________________________
Dosage Amounts _________________________________________________________________________________________
If we are to administer medication please place it is a sandwich bag with your Childs name and instructions in the bag.
Administering over the counter products: Is this okay? Yes________ No________

Pain Relievers such as: Tylenol / Aleve / Advil / Goody Powder / Female Related Items
Cold Medications / Sinus Medications / Allergy Tablets ARE NOT
Stomach Issues: Pepto Bismol / Imodium / Rolaids / Tums
Motion Sickness: Dramamine

Does Youth Participate Sleep Walk Yes _______________ No ______________
Date of last Doctor Checkup (approximate)_________________Date of Last Tetanus (approximate) _____________________
Allergic Reactions: Bee Stings ___________________ Penicillin _____________ Aspirin _____________________________
Other Allergies __________________________________________________________________________________________
Specific activities to be restricted ___________________________________________________________________________
_______________________________________________________________________________________________________
Reason for restriction _____________________________________________________________________________________
Special Physical/Emotional/Mental Concerns _________________________________________________________________
_______________________________________________________________________________________________________
Insurance Information: Company __________________________________________________________________________
Policy #’s _________________________________________ Phone Number ________________________________________
Medical Authorization and Release: In case of medical emergency I understand every reasonable effort will be made to contact parents or guardians of participants, using the information set forth above. In the event parents or guardians cannot by reached, I give permission to the physicians and hospital selected by the group leader to administer to the child named above the medical and surgical treatment then believed to be in the best interest of the child. The medical information on this form is complete and accurate. I agree to release and hold harmless Fort Creek Baptist Church, its officers and agents, from any liability to or responsibility for bodily injury, damage or illness to the above-identified child while participating in any youth athletic or social activity which may be directly or indirectly sponsored by the Church, including transportation. Further, I agree to indemnify and hold harmless the Church, its officers and agents with respect to any claim asserted by or on behalf of my child as a result of bodily injury, illness, or damage. Photographs & Videos are routinely captured of Youth. I agree that their picture may be published or developed for church use.
I certify that I am authorized to grant this authority and/or release. If participate is 18 or over they may sign this form themselves. Parent/Guardian Signature: ___________________________________________________ Date ______________________________
I understand this form is for all activities with Fort Creek Baptist Church and will be valid January 1, 2014 through December 31, 2014. 2014 Fort Creek Baptist Church
Please read and discuss this form with your child!
Youth Code of Conduct
Fort Creek Youth Group participants should exhibit Christian consideration, sensitivity, respect, and
maturity. We respectfully ask for your cooperation, and are sure that you will have no trouble
adhering to the following Code of Conduct.

Rules and regulations of the Youth Group MUST be followed!
Public Displays of Affection (PDA) / Sexual Misconduct No Violating the Dress Code – Dress Code Below Misuse or abuse of public and/or private property Do not share medications (please see a youth leader if a Possession or use of drugs or alcoholic beverages Christ-like behavior is expected at all times. Inappropriate contact, touch, gesture, language or activity of an offensive
nature is NOT ACCEPTABLE. Respect for all adult leaders, peers, and all property is expected.
At Fort Creek Baptist Church, we are all part of an environment where we are trying to remove distractions so that we
can concentrate on what GOD has brought us here to do. We do not want any student or adult to distract others by the
way they dress, or to be distracted by the way others dress. Should you choose to draw attention to yourself by
dressing inappropriately, you will be asked to change your clothes.
Dress should be representative of who we are as Christian students and Christian adults. We respectfully
ask for your cooperation, and are sure that you will have no trouble adhering to the following Dress Code.

(Please note: This dress code applies mainly to our youth who are church members and those that attend often. We want them to set
the example. However, we will be sensitive to Visitors and will address dress code violations with more grace.)

Here’s your guide, for not only Youth Activities but when attending Youth Bible Study or meetings:
No Spaghetti Straps. Tank Tops must follow 3 finger rule. No Strapless, no bare shoulders. No cleavage should ever show. Shirts cannot promote tobacco, alcohol, questionable saying, etc. Dresses follow same rule as tops and must be at an appropriate length, no short dresses. Must follow fingertip rule, fingers cannot touch AT ALL when your hands are by your sides. Athletic Shorts are okay with biker shorts under them. No “Message Shorts”. No sagging pants – undergarments do not show! Let your skin breath! No tight clothing. Ladies - One Piece and Tankinis are acceptable. Tankini top and bottoms must overlap. Bottoms cannot be “string” bottoms and tops cannot be strapless. Neither top nor bottom can be ALL white. Guys no Speedos (seriously, who wears those?!) In General – Appropriate dress & Modest dress are at the discretion of the Youth Minister, Youth Leaders & Senior Pastor. If youth participate is found in violation of the Code of Conduct or the Dress Code appropriate actions will have to be taken. On more serious offenses, his or her parent will be notified; the child will be suspended from all activities and may possibly be sent home immediately at the parent/guardian expense. I certify that my child and I have read and understood the above.
Parent/Guardian Signature _________________________________________________________________ Youth Participate Signature ________________________________________________________________ I understand this form is for all activities with Fort Creek Baptist Church and will be valid January 1, 2014 through December 31, 2014.

Source: http://fortcreek.org/clientimages/50152/2014%20waivers.pdf

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SKOKIE SCHOOL DISTRICT 73½ 2009-10 AUTHORIZATION TO ADMINISTER MEDICATION TO BE COMPLETED BY STUDENT'S PHYSICIAN School District 73½ policy states that medications, including over-the counter medications, may be administered to students only upon written request of the student's physician and parent. All medications must be brought to the nurse's office in the original container

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