Student Ministries Consent, Acknowledgement And

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Rancho Bernardo Community Presbyterian Church 17010 Pomerado Road, San Diego, CA 92128 ~ 858.487.0811

STUDENT MINISTRIES CONSENT, ACKNOWLEDGEMENT AND RELEASE Student Information Name Grade

Gender M/F Age

Birth Date

Address City

State

Email

Phone

Emergency Contact

Cell Number

Emergency Contact

Cell Number

Zip

List any Current Allergies, Illnesses, Physical Conditions or Medications

Name of Insurance

Primary Insured

Policy Number

Group Number

Participation Consent and Authorization I/We consent to and authorize my/our child to participate in ALL ministry events, activities, trips, excursions and programs conducted by the Rancho Bernardo Community Presbyterian Church (“Church”). I/We encourage my/our child to attend and stay for the duration of the activity/event and assume full responsibility if he/she does not attend or leaves early. I/We agree to provide transportation to and from church sponsored events. I/We recognize the church responsibility starts at beginning and ends at the conclusion of the event. I/We further agree to pick up my/our minor no later than twenty (20) minutes after the church activity/event. Transportation Consent and Authorization I/We consent to and authorize my/our child to be transported to and from church sponsored activities in a church, rental, or private vehicle. Communication Consent and Authorization I/We agree to monitor my/our child’s communication and outside interactions with adult ministry leaders and/or volunteers, including electronic communication. I/We agree to contact the church if I/We do not consent to the communication and/or outside interactions. Photo Release Consent and Authorization I/We understand that my/our child may be photographed and/or videotaped during his/her participation in events, activities, trips, excursions and programs conducted by the Church and consent to and authorize such photographs and/or videos to be used by the Church for ministry related presentations, publications and/or websites. I/We understand that my child’s name will not be used and/or published in any way, and that no compensation will be given for the use of such photographs and/or videos.

Rancho Bernardo Community Presbyterian Church

Student Ministries Consent, Acknowledgement And Release

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Medical/Dental Treatment Consent and Authorization I/We consent to any representative of the Church to authorize medical or dental treatment, including surgery or hospitalization, for my/our child for any injury or illness of an emergency nature, including necessary transportation to receive such treatment. Authorization is given in advance of any such medical or dental treatment as deemed advisable. A photocopy of this document shall have the same force and effect as the original. I/We hereby agree to pay any and all reasonable charges incurred as a result of any medical or dental treatment and to hold the Church and its representatives and officials harmless therefrom. Code of Conduct Consent and Authorization I/We agree to instruct my/our child to abide by all statements in the Code of Conduct. I/We agree that if my/our child fails to abide by the Code of Conduct, that my/our child may be dismissed from the activity/event and sent home at my/our expense for transportation or other fees with no right of reimbursement or refund for any amount. I/We further understand that my/our child will not be readmitted into future gatherings until parent(s)/guardian(s), ministry leader(s) and the student meet to discuss future participation in Student Ministries. Release of Liability and Agreement to Binding Arbitration I/We acknowledge that participation in Student Ministries events, activities, trips, excursions and programs of the Church involves risk to my/our child, and his/her parent(s)/guardian(s), and may result in various types of injury including, but not limited to the following: sickness, bodily injury, death, emotional injury, personal injury, property damage and financial damage. In consideration for the opportunity to participate in the ministry, I/we acknowledge and accept the risks of injury associated with participation in Student Ministries. I/We release the church of all liability for injury arising out of participation in the events. I/We accept personal financial responsibility for any injury sustained during participation. If a dispute over this agreement or any claim for damages arises, I/we agree to resolve the matter through binding arbitration with the American Arbitration Association. I/We represent and warrant that I/we are the parent(s) or legal guardian(s) of the minor student named above and maintain the authority to sign this document. Parent/Guardian Signature

Date

Parent/Guardian Signature

Date

STUDENT MINISTRIES CODE OF CONDUCT Students are expected to conduct themselves in a manner that reflects positively on themselves, their parent(s)/guardian(s) and our Church. Students are expected to respect the rights, feelings and property of others and the authority of ministry leaders, staff and volunteers.

Student Commitment I, , a participant in Student Ministries at Rancho Bernardo Community Presbyterian Church (RBCPC), commit to be respectful of staff, ministry leaders, my peers and property through my words and actions. I will abide by the Church’s policy of no bullying, hazing, invading personal space, inappropriate contact and/or harassment of any nature. Further, I will abide by the Church’s policy and not bring prohibited items to any gathering. I commit to do my part to make Student Ministries a positive experience for myself, my peers, staff, volunteers and ministry leaders at RBCPC. Student Signature

Date

Parent/Guardian Commitment I/We, , commit to do my/our part to make Student Ministries a positive experience for my/our child, his/her peers, staff, volunteers and ministry leaders at RBCPC. I/We agree and support the Student Ministries Code of Conduct of RBCPC. Parent/Guardian Signature

Date

Parent/Guardian Signature

Date

Rancho Bernardo Community Presbyterian Church

Student Ministries Consent, Acknowledgement And Release

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