2023-24 WPC Chaperone
Medical Release & Liability Waiver

Westminster Presbyterian Church
2701 Cameron Mills Road

Alexandria, VA, 22302

Consent & Child Protection Agreements



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.

If I wish to revoke this media permission, I will directly email Youth Pastor Olivia (o.patterson@wpc-alex.org) and Program Assistant Jessica Thurnes (j.thurnes@wpc-alex.org) to inform them and make any additional specifications.

I Agree


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 understand that I am always welcome to include or CC the Youth Pastor to ensure transparency. Should I ever feel unsure or uncomfortable about communication with a youth, I will send a copy or screenshot to the Youth Pastor and discuss with them how to proceed.

I Agree


The Youth Pastor and church staff who work with minors are all considered mandatory reporters under Virginia state law, meaning we have a legal responsibility to report suspected abuse, neglect, or exploitation of minors and vulnerable adults, including sexual exploitation.

As an adult volunteer working with minors, you are required to report this information to the Youth Pastor as quickly and discreetly as possible -- a) if you witness evidence or hear something about abuse, neglect, or exploitation; b) if a minor discloses to you anything about abuse of themselves or others; c) if a youth indicates intent to harm themself or others. If a youth wants to disclose something to you and asks for secrecy, please ask them to trust your discretion and allow them to share if you are comfortable. Once they have shared, or if you are not comfortable with them disclosing, encourage them to come with you to speak with the Youth Pastor; otherwise, make the report yourself. If the Youth Pastor is not available, please report to another Pastor; or to a Program Director if a pastor is not available.

I Agree

Medical Release & Waiver of Liability


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. 

I Agree


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 will not hold liable Westminster Session, pastors, directors, employees, youth advisors, chaperones, volunteers, or other agents ("Released Parties"), and I will 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 WPC 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. 5. WPC strongly recommends that I consult my health/medical insurance policy to determine whether I have adequate health and medical coverage. For international trips, WPC strongly recommends purchasing short-term international travel insurance.

6. The foregoing agreements shall extend to all programs and activities of the Westminster Youth Program, September 1, 2023 through August 31, 2024.

I Agree

By signing this waiver, I certify that I have carefully read these agreements & this liability waiver, and hereby agree to their terms.

Date: December 6, 2023

Please select who will be participating...
WPC Youth Ministry Covenant

While participating in any WPC Youth event, trip, or gathering on- or off-campus, I will treat others as members of my Christian family. I will love, respect, trust, support, and encourage others. I will help WPC Youth be a welcoming place that promotes inclusivity and the value of all people as God's children. 

1. When away from WPC, 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 by listening well and abiding by their rules. I will respond to them with gratitude for their hospitality.

2. I agree to abide by all rules laid out by the WPC Youth Staff and volunteers, and I will be respectful and kind to all Youth, Youth Staff, and volunteer leaders. 

3. As a volunteer with WPC 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, vaping devices, or prescription medications other than my own.
  • I WILL NOT engage in any behaviors of sexual harassment or bring/watch sexually inappropriate videos while participating in Westminster trips and events.

4. As a volunteer with WPC 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 for others.
  • Ask Youth leaders for care and concern when I need it.
  • Treat all people I encounter with love and respect. 

‚Äč5. Covid Measures: If ever/whenever there is a surge of transmission in COVID-19 cases, I agree to abide by all health & safety 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 WPC Youth gathering, event, or trip, both on- and off-campus.

I understand that breaking this covenant may result in me being asked to leave a trip, even at my own expense, and may lead to my removal as a chaperone or volunteer leader with WPC Youth.

Please refer all questions to Pastor Olivia (o.patterson@wpc-alex.org)

First Chaperone Name

First Name*

Last Name*
First Chaperone Date of Birth*
First Chaperone Information

What is your preferred name/nickname?

Chaperone Cell Phone #:
T-Shirt Size (Adult):*
First Chaperone Signature*
Parent or Guardian Email Address


Confirm Email*
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Participant Health Information

Primary Doctor *

Doctor Phone # *

Please share any pertinent medical information you'd like us to know, in the event of an emergency (surgeries, pins, food/medication allergies)

Please share any medications you'd like us to know you are taking, in the event of an emergency:

Please share any additional conditions or challenges you'd like our staff to be aware of, and how we can best support you at WPC Youth events:

Year of last Tetanus vaccine *
Health Insurance Information

Insurance Company

Company Phone #

Name of Policy Holder

Group #

Policy #
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 Name

First Name*

Last Name*

Parent or Guardian Date of Birth*
Parent or Guardian Information

What is your preferred name/nickname?

Chaperone Cell Phone #:
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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