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Youth at Convention 2011: “Taking It To The Streets” Date: November 11, 2011at 11:15am To: November 12, 2011 at 3:30pm Where: St. Paul’s Episcopal Church, 25 Westminster Road, Rochester, NY 14607 PARTICIPANT INFORMATION & REGISTRATION FORM REGISTRATION DEADLINE: October 21, 2011 Youth Name: _______________________F □ M □ Grade:____ Date of Birth:___________ Address: ______________________________________________________________________ City: ___________________________ State: __________________ Zip: __________________ Phone Number: ________________________ Email: _____________________________ Parish: _________________________________ Parish City: ______________________ OR Friend you are attending with: _____________________________________________________ T-Shirt Size (circle one): S M L XL Mother’s Name: _________________________ Home Phone: ___________________________ Cell Phone: ___________________Work Phone:__________________ Pager:______________ Father’s Name: _________________________ Home Phone: ___________________________ Cell Phone: ___________________Work Phone:___________________Pager:______________ In case of emergency, person to consult if parent(s)/guardian(s) cannot be reached: Name: _________________________ Home Phone: ___________________________ Cell Phone: ___________________Work Phone:___________________Pager:______________ HEALTH HISTORY Name of family doctor: ___________________________________ Phone:____________________ Address:______________________________________________________________________ Health insurance company: ______________________________Policy #: _______________ Major health problems or allergies (including food allergies):______________________________________________________________________ ______________________________________________________________________________ Special needs (dietary, physical, other): _____________________________________________________________ Anything else we need to know in order to care for participant? _________________________________________ Medications (e.g. inhalers): _______________________________________________________________________ ALL MEDICATIONS, INCLUDING OVER THE COUNTER MEDICATIONS, MUST BE KEPT IN THE POSSESSION OF THE PARTICIPANT AND SELF-ADMINISTERED. PARTICIPANT MUST NOT SHARE ANY MEDICATIONS WITH OTHERS. CONSENT TO EVENT, USE OF PHOTOS, AND EMERGENCY MEDICAL TREATMENT I consent to having my son/daughter take part in this event. In the event of an emergency, I wish to have _____________________________________________ (designated chaperone) or, or a person designated by him/ her, take whatever steps and decisions are necessary to protect my child's health if the parent(s)/ guardian(s)/ emergency contact above cannot be reached. The medical information listed above is complete and correct, to the best of my knowledge. I assume responsibility for payment of all medical treatment received. I/ We GRANT permission for photos/images of my child to be used in the Episcopal Diocese of Rochester’s print and electronic publications. I/We DO NOT GRANT permission for photos/images of my child to be used in the Episcopal Diocese of Rochester’s print and electronic publications. Parent/Guardian or Chaperone signature: _____________________________________ Date: ________________ YOUTH COMMUNITY NORMS CONTRACT Youth at Convention 2011: “Taking It To The Streets” November 11, 2011 (11:15 pm) to November 12, 2011 (3:30 pm) In order to promote healthy, loving and inclusive Christian community during our times together, the following norms have been developed for youth events: 1. All participants will abstain from the use or possession of tobacco products, illegal drugs and alcohol. 2. Electronic devices such as CD players, radios, cell phones are not permitted during church service time only. 3. Any interpersonal conflict among participants will be managed and resolved without use of violence. No knives or other weapons will be brought to our events. All participants agree to treat others with respect and kindness at all times. 4. All participants agree to abstain from all sexual activity during our times together, which includes all activity that marks individuals as a “couple,” such as kissing. Even if participants are a “couple” before coming to an event, they will not behave as such while at Zion. 5. As a community we are committed to affirming the dignity of every person, and so discriminatory behavior based on race, color, ethnicity, ancestry, gender, sexual orientation, physical disability, physical appearance or other personal attributes is not welcome among us. 6. All participants are required to remain on site with advisors until the conclusion of the program when authorized transportation is available. My parent(s) or guardian(s) and I have read and understand the norms listed above, and I agree to live by them during this overnight event. I understand that if I refuse to abide by these norms, I may be sent home from this event. Parent(s) or guardian(s) will be responsible for transporting participants’ home in the event of such a problem. Participant's signature_____________________________________________________________ Parent(s) or Guardian(s) signature____________________________________________________Date______ Completed registration forms must be mailed to St. Luke’s Church, Attn: Jessica Longstreth, 14 State Street, Brockport, NY 14420 by October 21st, 2011.
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