2020 Parental Consent and Code of Conduct

Locust Valley Chapel 5936 Locust Valley Road, Coopersburg, PA 18036
OFFICE: (610) 282-3881 FAX: (610) 282-6124

www.locustvalleychapel.org Email: locustvalleychapel@gmail.com

Date

Parents Name

Students Name

Students DOB and Age

Address

Phone

Parental/Guardian Consent Form for Activities (Blanket Permission)

I am the parent or legal guardian of the child stated above and I am informed of the activities offered by Locust Valley Chapel, located in Coopersburg, PA, County of Lehigh, and State of Pennsylvania, beginning on the day of February 1, 2019 and ending on the day of February 1, 2020. As the parent or legal guardian of my child, I hereby consent for my child to attend and participate in all activities provided by Locust Valley Chapel.

Yes

Secondary Contact Person in Case of Emergency

Secondary Contact Phone Number in Case of Emergency

Release

I understand that the Church staff and adult supervisors will endeavor to provide individual care and safety for each participant in each activity and/or program. I am aware that neither the Church nor any member of its staff or adult supervisors can assume responsibility for any injury or damage, which may occur in connection with such program or activity. Therefore, by signing this form I am agreeing to the Legal Release of Liability, by which I am releasing the Church, its staff and volunteers from liability arising out of any Church-sponsored activity in which my child participates.

Yes

Medical

Insurance Information: (Company, Policy Number, Group Number)

List Any Allergies

Current Medications and Dosage

If needed, my child can take...

Ibprophen Tylenol Cold/Cough Med Pepto Nothing

Immunizations Up To Date

Yes No

Anything else we need to be aware of concerning your child?

Media

Locust Valley Chapel can use my child’s image for publication either digital or in physical form for promotional uses.

Yes No

Code of Conduct

For your information, we expect each student to conform to these rules of conduct.

Possession or use of alcohol, drugs or tobacco is not allowed

Students cannot drive

Fighting will not be tolerated.

Weapons (including knives), fireworks, lighters, or explosives are not allowed.

Offensive or immodest clothing is not allowed

No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters

Participation with the group is expected

Respect property, staff, one another, and leaders is expected

Respect and comply with event schedules.

Respect personal boundaries. Inappropriate contact will not be tolerated

No pairing off, students must be in groups of three or more.

Students who fail to comply with these expectations may be sent home at their parents’ expense.

I, the student, have read the rules of conduct, the above evaluation of my health, and have granted permission to participate in youth group activities. I agree to abide by the stated personal limitations and Code of Conduct.

Yes

I, the parent/guardian, have read the rules of conduct, and understand that my child/student has signed the above statement and is willing to work within the stated Code of Conduct.

Yes

Parents/guardians please print this form, sign, date, and return to Pastor Rick or the church office:

Signature:________________________________________

Date: ______________________

2020 Parental Consent and Code of Conduct

Description

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