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PERMISSION & LIABILITY WAIVER

Virginia Beach UMC C.R.E.W. Youth Ministry

School Year Participation Form

Effective Dates: September 1, 2023 -August 31, 2024

The undersigned do(es) hereby give permission for our (my) child (“Participant”), to attend and participate in Virginia Beach United Methodist Church (VBUMC) youth ministry activities and events on VBUMC property and/or property of its volunteers, employees or representatives from September 1, 2022 through August 31, 2023. We (I) the undersigned, do hereby release, forever discharge and agree to hold harmless Virginia Beach United Methodist Church, its directors, employees, volunteers, and agents (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the youth activities. We (I) the parent(s) or legal guardian(s) of this Participant hereby grant our (my) permission for the Participant to participate fully in youth ministry activities, including trips away from the church premises. Furthermore, we (I) [and on behalf of our (my) minor Participant(s)] hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said Church to furnish any necessary transportation (within the limitations of church insurance and the law), food and lodging for this Participant. The undersigned further hereby agree to hold harmless and indemnify said Church for any liability sustained by said Church as the result of negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned youth pursuant to this authorization.

EARLY RETURN HOME POLICY: Should it be necessary for our (my) youth to return home from a VBUMC youth ministry activity due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for our (my) youth to ride in any vehicle driven by an approved ADULT chaperone while attending and participating in activities sponsored by Virginia Beach United Methodist Church. My youth and I understand that SEAT BELTS SHALL BE WORN AT ALL TIMES during transportation.


VBUMC C.R.E.W.

Student Code of Conduct Covenant

Rules and guidelines are put in place to help maintain a safe environment for everyone involved. The rules and guidelines set in this Code of Conduct will help minimize conflicts among the group and maximize growth and unity in our ministry. 

  • I will demonstrate a willingness to learn and grow in the Christian faith and reflect Jesus Christ with my thoughts, words, and actions.
  • I will respect myself and other people, obeying the instructions of the staff and leaders.
  • I will encourage participation and not cause disruptions. I will model this behavior. 
  • I will keep my cell phone and other personal electronic devices stored away when involved in Youth activities and when I serve as a volunteer.
  • I will respect and properly care for equipment, facilities and supplies.
  • I will be an encourager, not one who ridicules, makes fun of, shares gossip, or criticizes.
  • I will deal peacefully with anger and disagreements and bring conflicts to the attention of the Director of Youth Ministry.
  • I will refrain from using obscene language.
  • I understand that public displays of affection at church can be distracting and inappropriate. I will refrain from excessive and obvious romantic behavior during youth-sponsored activities.  
  • I will respect the zero-tolerance policy for recreational drugs, vaping, alcohol, tobacco, and weapons. 
  • I will wear appropriate clothing.
  • I will abide by the instructions of leaders and staff.

I have read and understand the rules and guidelines in this Code of Conduct and will abide by them at all times. I understand and agree that my failure to meet these expectations may result in a meeting with the Director of Youth Ministry to counsel future behavior.

Date: July 24, 2024

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Grade 2023-2024:

School:

Youth Phone:
MEDIA RELEASE CONSENT: Virginia Beach United Methodist Church is authorized to use photographic and/or videotaped images of my child in future church publications. Publications include the church web site, newsletters and social media pages. Youth names will not be published. In providing consent, I agree that I do not and will not require financial compensation. *
Yes
No

Date of last tetanus shot:

Medications / Allergies

Please list all medications that your youth might have the occasion to use while participating in any youth function, this includes but is not limited to allergy medication, inhalers, migraine medicines, behavior modifying medications, etc. This information will be kept confidential, but this form will be available for those leaders of the youth during emergency situations. If none, please write NONE in this space.


What is taken

How it is taken

When it is taken

Why it is taken
While on this event, should your youth be allowed to have common pain reducing drugs such as Aspirin, Tylenol, Ibuprofen? *
No
Yes

If yes, which types?

Please list allergies & treatment for allergy (food, medicine, other):
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Grade 2023-2024:

School:

Youth Phone:
MEDIA RELEASE CONSENT: Virginia Beach United Methodist Church is authorized to use photographic and/or videotaped images of my child in future church publications. Publications include the church web site, newsletters and social media pages. Youth names will not be published. In providing consent, I agree that I do not and will not require financial compensation. *
Yes
No

Date of last tetanus shot:

Medications / Allergies

Please list all medications that your youth might have the occasion to use while participating in any youth function, this includes but is not limited to allergy medication, inhalers, migraine medicines, behavior modifying medications, etc. This information will be kept confidential, but this form will be available for those leaders of the youth during emergency situations. If none, please write NONE in this space.


What is taken

How it is taken

When it is taken

Why it is taken
While on this event, should your youth be allowed to have common pain reducing drugs such as Aspirin, Tylenol, Ibuprofen? *
No
Yes

If yes, which types?

Please list allergies & treatment for allergy (food, medicine, other):
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Grade 2023-2024:

School:

Youth Phone:
MEDIA RELEASE CONSENT: Virginia Beach United Methodist Church is authorized to use photographic and/or videotaped images of my child in future church publications. Publications include the church web site, newsletters and social media pages. Youth names will not be published. In providing consent, I agree that I do not and will not require financial compensation. *
Yes
No

Date of last tetanus shot:

Medications / Allergies

Please list all medications that your youth might have the occasion to use while participating in any youth function, this includes but is not limited to allergy medication, inhalers, migraine medicines, behavior modifying medications, etc. This information will be kept confidential, but this form will be available for those leaders of the youth during emergency situations. If none, please write NONE in this space.


What is taken

How it is taken

When it is taken

Why it is taken
While on this event, should your youth be allowed to have common pain reducing drugs such as Aspirin, Tylenol, Ibuprofen? *
No
Yes

If yes, which types?

Please list allergies & treatment for allergy (food, medicine, other):
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Grade 2023-2024:

School:

Youth Phone:
MEDIA RELEASE CONSENT: Virginia Beach United Methodist Church is authorized to use photographic and/or videotaped images of my child in future church publications. Publications include the church web site, newsletters and social media pages. Youth names will not be published. In providing consent, I agree that I do not and will not require financial compensation. *
Yes
No

Date of last tetanus shot:

Medications / Allergies

Please list all medications that your youth might have the occasion to use while participating in any youth function, this includes but is not limited to allergy medication, inhalers, migraine medicines, behavior modifying medications, etc. This information will be kept confidential, but this form will be available for those leaders of the youth during emergency situations. If none, please write NONE in this space.


What is taken

How it is taken

When it is taken

Why it is taken
While on this event, should your youth be allowed to have common pain reducing drugs such as Aspirin, Tylenol, Ibuprofen? *
No
Yes

If yes, which types?

Please list allergies & treatment for allergy (food, medicine, other):
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Grade 2023-2024:

School:

Youth Phone:
MEDIA RELEASE CONSENT: Virginia Beach United Methodist Church is authorized to use photographic and/or videotaped images of my child in future church publications. Publications include the church web site, newsletters and social media pages. Youth names will not be published. In providing consent, I agree that I do not and will not require financial compensation. *
Yes
No

Date of last tetanus shot:

Medications / Allergies

Please list all medications that your youth might have the occasion to use while participating in any youth function, this includes but is not limited to allergy medication, inhalers, migraine medicines, behavior modifying medications, etc. This information will be kept confidential, but this form will be available for those leaders of the youth during emergency situations. If none, please write NONE in this space.


What is taken

How it is taken

When it is taken

Why it is taken
While on this event, should your youth be allowed to have common pain reducing drugs such as Aspirin, Tylenol, Ibuprofen? *
No
Yes

If yes, which types?

Please list allergies & treatment for allergy (food, medicine, other):
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Grade 2023-2024:

School:

Youth Phone:
MEDIA RELEASE CONSENT: Virginia Beach United Methodist Church is authorized to use photographic and/or videotaped images of my child in future church publications. Publications include the church web site, newsletters and social media pages. Youth names will not be published. In providing consent, I agree that I do not and will not require financial compensation. *
Yes
No

Date of last tetanus shot:

Medications / Allergies

Please list all medications that your youth might have the occasion to use while participating in any youth function, this includes but is not limited to allergy medication, inhalers, migraine medicines, behavior modifying medications, etc. This information will be kept confidential, but this form will be available for those leaders of the youth during emergency situations. If none, please write NONE in this space.


What is taken

How it is taken

When it is taken

Why it is taken
While on this event, should your youth be allowed to have common pain reducing drugs such as Aspirin, Tylenol, Ibuprofen? *
No
Yes

If yes, which types?

Please list allergies & treatment for allergy (food, medicine, other):
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Grade 2023-2024:

School:

Youth Phone:
MEDIA RELEASE CONSENT: Virginia Beach United Methodist Church is authorized to use photographic and/or videotaped images of my child in future church publications. Publications include the church web site, newsletters and social media pages. Youth names will not be published. In providing consent, I agree that I do not and will not require financial compensation. *
Yes
No

Date of last tetanus shot:

Medications / Allergies

Please list all medications that your youth might have the occasion to use while participating in any youth function, this includes but is not limited to allergy medication, inhalers, migraine medicines, behavior modifying medications, etc. This information will be kept confidential, but this form will be available for those leaders of the youth during emergency situations. If none, please write NONE in this space.


What is taken

How it is taken

When it is taken

Why it is taken
While on this event, should your youth be allowed to have common pain reducing drugs such as Aspirin, Tylenol, Ibuprofen? *
No
Yes

If yes, which types?

Please list allergies & treatment for allergy (food, medicine, other):
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Grade 2023-2024:

School:

Youth Phone:
MEDIA RELEASE CONSENT: Virginia Beach United Methodist Church is authorized to use photographic and/or videotaped images of my child in future church publications. Publications include the church web site, newsletters and social media pages. Youth names will not be published. In providing consent, I agree that I do not and will not require financial compensation. *
Yes
No

Date of last tetanus shot:

Medications / Allergies

Please list all medications that your youth might have the occasion to use while participating in any youth function, this includes but is not limited to allergy medication, inhalers, migraine medicines, behavior modifying medications, etc. This information will be kept confidential, but this form will be available for those leaders of the youth during emergency situations. If none, please write NONE in this space.


What is taken

How it is taken

When it is taken

Why it is taken
While on this event, should your youth be allowed to have common pain reducing drugs such as Aspirin, Tylenol, Ibuprofen? *
No
Yes

If yes, which types?

Please list allergies & treatment for allergy (food, medicine, other):
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Grade 2023-2024:

School:

Youth Phone:
MEDIA RELEASE CONSENT: Virginia Beach United Methodist Church is authorized to use photographic and/or videotaped images of my child in future church publications. Publications include the church web site, newsletters and social media pages. Youth names will not be published. In providing consent, I agree that I do not and will not require financial compensation. *
Yes
No

Date of last tetanus shot:

Medications / Allergies

Please list all medications that your youth might have the occasion to use while participating in any youth function, this includes but is not limited to allergy medication, inhalers, migraine medicines, behavior modifying medications, etc. This information will be kept confidential, but this form will be available for those leaders of the youth during emergency situations. If none, please write NONE in this space.


What is taken

How it is taken

When it is taken

Why it is taken
While on this event, should your youth be allowed to have common pain reducing drugs such as Aspirin, Tylenol, Ibuprofen? *
No
Yes

If yes, which types?

Please list allergies & treatment for allergy (food, medicine, other):
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Grade 2023-2024:

School:

Youth Phone:
MEDIA RELEASE CONSENT: Virginia Beach United Methodist Church is authorized to use photographic and/or videotaped images of my child in future church publications. Publications include the church web site, newsletters and social media pages. Youth names will not be published. In providing consent, I agree that I do not and will not require financial compensation. *
Yes
No

Date of last tetanus shot:

Medications / Allergies

Please list all medications that your youth might have the occasion to use while participating in any youth function, this includes but is not limited to allergy medication, inhalers, migraine medicines, behavior modifying medications, etc. This information will be kept confidential, but this form will be available for those leaders of the youth during emergency situations. If none, please write NONE in this space.


What is taken

How it is taken

When it is taken

Why it is taken
While on this event, should your youth be allowed to have common pain reducing drugs such as Aspirin, Tylenol, Ibuprofen? *
No
Yes

If yes, which types?

Please list allergies & treatment for allergy (food, medicine, other):
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Participant's 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:*
Additional Information

Emergency Contacts (in case Parent / Guardian can’t be reached)


Name: *

Phone #: *

Name:

Phone #:

Insurance Information

Medical Insurance? *
No
Yes

Insurance Company:

Policy #:

Phone #:
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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

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

Grade 2023-2024:

School:

Youth Phone:
MEDIA RELEASE CONSENT: Virginia Beach United Methodist Church is authorized to use photographic and/or videotaped images of my child in future church publications. Publications include the church web site, newsletters and social media pages. Youth names will not be published. In providing consent, I agree that I do not and will not require financial compensation. *
Yes
No

Date of last tetanus shot:

Medications / Allergies

Please list all medications that your youth might have the occasion to use while participating in any youth function, this includes but is not limited to allergy medication, inhalers, migraine medicines, behavior modifying medications, etc. This information will be kept confidential, but this form will be available for those leaders of the youth during emergency situations. If none, please write NONE in this space.


What is taken

How it is taken

When it is taken

Why it is taken
While on this event, should your youth be allowed to have common pain reducing drugs such as Aspirin, Tylenol, Ibuprofen? *
No
Yes

If yes, which types?

Please list allergies & treatment for allergy (food, medicine, other):
Parent or Guardian's 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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