Youth_at_Convention_Registration_form

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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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