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2021-2022 Chaperone Medical Form
​and Liability Waiver

Westminster Presbyterian Church
2701 Cameron Mills Road
Alexandria, VA, 22302
703-549-4766

Westminster Presbyterian Youth Ministry Covenant

While participating in any Westminster Presbyterian Youth event, trip, or gathering on- or off-campus, I will do my best to live together with others as a family in Christian community. I will love, respect, trust, support, and encourage others. I will seek to create and maintain a safe atmosphere that promotes inclusivity and the value of all people as God's children. 

1. When away from Westminster Presbyterian Church, I will recognize that I am a guest to our hosts. As a guest, I will be considerate to our hosts and to their leadership team. I will respond to them with gratitude for their hospitality.

2. I agree to abide by all rules laid out by the Westminster Presbyterian Youth staff and volunteers, and I will be respectful of all Youth staff and volunteer leaders.

3. As a member of Westminster Presbyterian Youth:

  • I WILL NOT bring or use any harmful substances or weapons including, but not limited to: weapons of any kind, fireworks, drugs, alcohol, tobacco products, or prescription medications other than my own.
  • I WILL NOT engage in any behaviors of sexual harassment or bring/watch sexually explicit videos while participating in Westminster trips and events.

4. As a member of Westminster Presbyterian Youth, I WILL:

  • Be responsible for my own belongings and respect the property of others.
  • Participate with a good attitude, as I am able, in all activities of the youth ministry trips and events.
  • Care for and be respectful of the property of Westminster and/or our hosts.
  • Be appropriate in my expressions of care and concern.
  • Ask Youth leaders for care and concern when I need it.
  • Treat all people I encounter with love and respect. 

​5. Covid Measures: During the ongoing pandemic of the novel coronavirus, COVID-19, and the declaration of a global pandemic by the World Health Organization (WHO), I agree to abide by all guidelines set forth by the Session of Westminster Presbyterian Church, which are set in accordance with recommendations from the Centers for Disease Control (CDC). I agree to follow any additional measures put in place by Youth staff and volunteers, our hosts, guidelines in other states, or event venues where we may participate.

As a participant in the Youth Ministry of Westminster Presbyterian Church, I agree to abide by this covenant while participating in any Westminster Youth gathering, event, or trip, both on- and off-campus. I understand that breaking this covenant may result in my parents or guardians being notified, and that I may be asked to go home at my parents' or guardians' expense. Moreover, I will not be allowed to participate in Westminster events until it is determined that I can abide by the guidelines of this covenant.

Please refer all questions to:
Olivia Patterson
Associate Pastor for Youth & Young Adults
o.patterson@wpc-alex.org
770-654-9202

Date: June 28, 2022

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First Chaperone Name

First Name*

Last Name*

Phone*
First Chaperone Date of Birth*
First Chaperone Information

Goes By:
T-Shirt Size (Adult):*
First Chaperone Signature*
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Participant Health Information

Primary Doctor *

Doctor Phone # *

Pertinent Medical History & Known Allergies (esp. to foods & medications)

Regular Medication (in case of drug interactions)

Do you have any other physical or emotional limitations we should know about? Please contact the Youth Pastor if it would be helpful to discuss.

Year of last Tetanus vaccine *

Date of last Covid vaccine *
Health Insurance Information

Insurance Company

Company Phone #

Name of Policy Holder

Group #

Policy #
Consent Agreements and Liability Release

AGREEMENT FOR MEDIA RELEASE

I grant my permission for Westminster staff or designated adult volunteers to photograph and film me during Westminster activities and trips, understanding that my image may be used in promotional materials or otherwise published in print or digital form. Note that names will not be used with any image or likeness in church-related publications or on the website unless special permission is sought and received.

If I wish to revoke this media permission, I will directly email the Youth Pastor/Director and current Program Assistant (Jessica Thurnes) with any additional specifications.

AGREEMENT FOR CONTACT IN MINISTRY

As an adult volunteer, I agree to keep a record of written communication with any youth (e.g. save emails, cell providers can access texts). I agree to avoid private messaging any youth via my personal social media accounts unless first contacted by Youth (e.g. DMs). I understand that Westminster staff and volunteers may NOT participate in image or video messaging with any youth over social media (e.g. Snapchat). I agree that all communication with youth will abide by the Westminster Child Protection Policy and follow the direction of the Westminster Session, pastors, and staff. I am always welcome to copy or include the Youth Pastor/Director to ensure transparency, and should I ever feel unsure or uncomfortable about communication with a youth, I will send written copy to the Youth Pastor/Director and discuss with them how to proceed. 

AGREEMENT FOR MEDICAL TREATMENT

In the event of injury, illness, or medical emergency, if I am unable to make medical decisions and my emergency contact cannot be reached, I hereby authorize the Westminster staff and chaperones to procure any medical attention they consider necessary and expedient for me.

I agree to pay for all expenses incurred for medical attention I receive while participating in any Westminster Presbyterian Church-sponsored activity.

I understand that it is my responsibility to provide medical coverage for myself and agree to notify Westminster and relevant staff if and when our medical coverage changes. I also understand that Westminster staff reserve the right to restrict me from any activity that they feel is not within their physical, mental, or emotional capabilities at a given time. 

AGREEMENT TO WAIVE LIABILITY

Westminster Presbyterian Church (hereafter referred to as "Westminster"), 2701 Cameron Mills Road, Alexandria, Virginia, 22302, is a non-profit church organization and a member church of the Presbyterian Church (USA). The undersigned ("Chaperone") desires to participate in programs and activities sponsored by the Westminster Youth Program. For Westminster to permit the participation of the Chaperone in such programs, I hereby agree to the following:

1. I acknowledge that there are potential dangers in participating in all programs sponsored by the Westminster Youth Program, including traveling to and from mission sites and working at mission sites. Thus, I agree that I participate at my own risk and assume full responsibility for personal injury and property damage I may sustain while participating in such programs.

2. I shall not hold liable Westminster Session, pastors, directors, employees, chaperones, volunteers, or other agents ("Released Parties"), nor shall I hold them harmless for any claims, demands, injuries, damages, actions, or cause of actions by others in the course of or resulting from my participation in Westminster events and activities.

3. I hereby expressly forever release and discharge Released Parties from all such claims, demands, injuries, damages, actions, or causes of action, and from all acts of passive or active negligence on the part of Released parties.

4. I agree not to sue or make a claim against the released parties for injury, damage, or loss sustained as a result of my participation in the Westminster trips or activities. I agree to indemnify, defend, and hold harmless the Released Parties from all claims, judgments, and costs, including attorney's fees, incurred in connection with any action brought by me or on my behalf.

5. Westminster strongly recommends that I consult my health/medical insurance policy to determine whether they have adequate health and medical coverage. 

6. The foregoing agreements shall extend to all programs and activities of the Westminster Youth Program, September 1, 2021 through August 31, 2022.

AGREEMENT TO WAIVE COVID LIABILITY

Westminster Presbyterian Church has enacted preventative measures suggested by the Centers for Disease Control and Federal, State, and Local Government to reduce the spread of COVID-19. However, Westminster cannot guarantee that you will not become infected with COVID-19. Further, attending Westminster activities or trips may increase the risk of you and/or your family contracting COVID-19. By signing this agreement, I agree to follow Westminster COVID-19 protocols. I acknowledge the highly contagious nature of COVID-19 and voluntarily assume the risk that I and/or my family may be exposed to or infected by COVID-19 by participating in Westminster activities and trips. I also acknowledge the risk that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand the risk of becoming exposed to or infected by COVID-19 at Westminster activities and trips.

PLEASE READ CAREFULLY - THIS RELEASE AND WAIVER IS A LEGAL DOCUMENT.

BY SIGNING THIS WAIVER, I CERTIFY THAT I HAVE CAREFULLY READ ALL THESE AGREEMENTS AND AGREE TO THEIR TERMS. 

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian Date of Birth*
Parent or Guardian Information

Goes By:
T-Shirt Size (Adult):*
Parent or Guardian Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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