Wellness Agreement and Photo Release for St. Andrew's

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Description of event:
This form is for our Children’s Chapel on the Lawn is for ages 3 – 10 and for EYC (in-person) Gatherings (grades 6 - 12) for summer 2021.

These offerings will meet on the grounds of St. Andrew’s Episcopal Church, 1009 W. Princess Anne Road, Norfolk, VA 23507. The instructors for this offering are St. Andrew’s leaders and helpers. We will meet in either outside on the Auditorium lawn or the White Hall patio. With days of inclement weather or temperatures are over 90 degrees, we will meet inside in the Auditorium or White Hall with windows open and masks worn.

To safeguard the health of all, youth and their parent(s) or guardian(s) must commit to following a set of expectations and norms to minimize the transmission of COVID-19. These standards are the recommendations of medical and public health professionals and meet or exceed federal and state guidelines. All youth who plan to participate in the event outlined in the description of event section must commit to the expectations below. Please be sure to discuss these agreements and the rationale for them with each youth before signing.

*Please note, you may include all children on one form.

Email *

First and Last Name *

Birthday and Age *

Grade completed at the end of June 2021 *

Allergies / Special Needs

Photo Release *

Yes, you have my permission to use my child’s/children’s photo in parish publications and electronic media formats. * Please note St. Andrew’s never shares childrens’ names.

No, do not use my child’s/children’s photo in any parish publications or electronic media formats.

Required

Personal Care: *

- I agree to sanitize my hands with soap and water or hand sanitizer thoroughly and regularly.

- I agree to maintain a physical distance of three feet from other people, including children and adults, while at church or youth events.

- I agree to bring a cloth face covering that covers my nose and mouth when coming to the youth event. I will wear this face covering in the proper expected manner while at church or participating in Christian Formation or youth activities.

- I agree that I (or my family) will monitor myself daily for COVID-19 symptoms including elevated temperature, muscle aches, loss of taste and/or smell, coughing, and gastrointestinal symptoms such as diarrhea, nausea or vomiting.

- I agree to contact my family physician if I have any suspected COVID-19 symptoms.

- I agree that I (or my family) will take my temperature prior to each visit to church/youth event and will answer any basic questions about my health. I also agree to permit the taking of my temperature at church/youth event by a responsible adult upon request.

- If I am not feeling well, I will not attend any Christian Formation or youth event.

Check yes here, if you agree to all of these statements.

Required

Pledge of Commitment *

- I agree to the expectations set forth in this agreement for the duration of the 2020-21 Christian Education year.

- I understand that I may be asked to leave if it is determined that I am not upholding these expectations.

- I understand that my decisions and behaviors could potentially impact the health and safety of all members of the church and the broader community, including my own well-being in addition to the well-being of my peers and other members of the church.

- I have discussed this agreement with my parent(s)/guardian(s) (or youth). Please sign and submit a copy of this agreement for each youth participant.

Check yes here, if you agree to all of these statements.

Required

Child's/Children's Signature and Date *

Parent's Signature and Date *

Thank you for your response.

Send me a copy of my responses.

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