2023-24 WPC Youth
Medical Release & Liability Waiver

Westminster Presbyterian Church
2701 Cameron Mills Road
Alexandria, VA, 22302

Consent Agreements & Waiver of Liability


This section must be completed by a legal parent/guardian, even if a youth has already turned 18.


I ("Guardian") grant my permission for my legal dependent ("Youth"), named in the "Participant Information" section of this form, to travel to and from and to participate in Westminster Presbyterian Church trips and activities, under the direction of the Westminster Session, staff, and volunteer youth advisors, from September 1, 2023 to August 31, 2024.

I grant my permission for Westminster staff or designated adult chaperones to transport my Youth for youth trips and activities. All activities will follow the Child Protection Policy set forth by Westminster Presbyterian Church.

I Agree


I grant my permission for Westminster staff or designated adult volunteers to photograph and film my Youth during Westminster activities and trips, understanding that my Youth's 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 (opatterson@wpc-alex.org) and Program Assistant Jessica Thurnes (jthurnes@wpc-alex.org) to formally revoke permission and specify any additional requirements.

I Agree


I grant my permission for Westminster staff or designated adult volunteers to contact my Youth by mail, email, phone, texting, and/or official WPC social media accounts as needed in their ministry to my Youth. All communication will continue to abide by the Westminster Child Protection Policy and follow the direction of the Westminster Session, pastors, and staff. Additionally, no Westminster staff or volunteers will participate in image or video messaging with any Youth over social media (e.g. Snapchat).

If I wish to revoke this contact permission, I will directly email Youth Pastor Olivia and specify how Youth staff and/or volunteers should communicate with my Youth.

I Agree


As this Youth's legal guardian, if I cannot be contacted in the event of injury, illness, or medical emergency, I hereby authorize the Westminster staff and chaperones to procure any medical attention they consider necessary and expedient for my Youth.

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

I understand that it is my/our responsibility to provide medical coverage for Youth and agree to notify Westminster and relevant staff if and when our medical coverage changes.

I understand that Westminster staff and volunteers reserve the right to restrict my Youth 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 "WPC"), 2701 Cameron Mills Road, Alexandria, Virginia, 22302, is a non-profit church organization and a member church of the Presbyterian Church (USA). The undersigned ("Guardian") is the parent or legal guardian(s) of ("Youth") and desires the Youth to participate in programs and activities sponsored by WPC Youth Ministry.

For WPC to permit the participation of the Youth 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 WPC Youth Ministry, including traveling to and from mission sites and working at mission sites. Thus, I agree that my Youth participate at Youth's own risk and assume full responsibility for personal injury and property damage sustained by the Youth 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 Youth's 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, on my behalf and on behalf of the Youth, not to sue or make a claim against the released parties for injury, damage, or loss sustained as a result of the Youth's 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 or on behalf of the Youth and/or the undersigned Guardian.

5. WPC strongly recommends that Guardian and Youth consult their health/medical insurance policy to determine whether they have adequate health and medical coverage. For international trips, WPC strongly recommends purchasing short-term travel insurance.

6. The foregoing agreements shall extend to all programs and activities of Westminster Presbyterian Church Youth Ministry from 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.

December 6, 2023

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

This section to be completed by the participating youth:

While participating in any Westminster Presbyterian 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 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 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 Westminster Presbyterian Youth staff and volunteers, and I will be respectful and kind to all Youth, 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, 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 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 for others.
  • Ask Youth leaders for care and concern when I need it.
  • Treat all people I encounter with love and respect. 

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 my parent/guardian(s) being notified and that I may be asked to go home at the expense and/or inconvenience of my parent/guardian(s). 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 Pastor Olivia (o.patterson@wpc-alex.org)

First Youth Name

First Name*

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

What is your preferred name/nickname?

Youth Cell Phone #:

Youth Email Address:

Grade: *

School: *
T-Shirt Size (Adult):*
First Youth Signature*
Youth Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Health Insurance Information

Insurance Company *

Company Phone # *

Name of Policy Holder *

Group # *

Policy # *
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 your student is taking, in the event of an emergency:
Check here if:
I want you to remind my Youth to take their medication
I want Westminster staff to keep and administer my child's medication

Year of last tetanus shot:
Mental Health & Neurodivergence

Mental health conditions/symptoms like depression, anxiety, insomnia, low esteem, and suicidal thoughts are common among teenagers, and even more so among LGBTQIA+ youth. If you or your youth need support or help finding mental health resources, please contact one or all of the WPC pastors.

We have a lot of neurodiversity at WPC! We have many members with autism, ADHD, Down syndrome, learning difficulties, and more; as well as many members with mental health conditions. We want to both affirm the gifts that come with neurodiversity and walk with your youth and family when challenges arise.

Please share any conditions or challenges you'd like our staff to be aware of and how we can best support your youth at WPC events:
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent/Guardian Email Address


Confirm Email*

Parent(s) or court-appointed legal guardian(s) hereby agree that all of the above information is, to the best of their knowledge, correct.

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (defined by WPC Youth as under 18 & 18+ students still in high school) 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/Guardian Name

First Name*

Last Name*

Parent/Guardian Date of Birth*
Parent/Guardian Information

What is your preferred name/nickname?

Youth Cell Phone #:

Youth Email Address:

Grade: *

School: *
T-Shirt Size (Adult):*
Parent/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.

One or more problems exist. Please scroll up.

Powered by  Smartwaiver - TRY IT FREE!