CotA Youth: Info, Conduct, Medical, Liability, & Media Release 23'-24' School Year
Please complete this form for your student to participate in youth activities beginning Fall 2023

Church of the Apostles          Micah McCoy - Youth Director
1520 Bull St                                    704-657-0514
Columbia, SC 29201          micah@apostlescolumbia.org
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Email *
Email *
Student First Name *
Student Last Name *
Student Middle Name
Age
Birthday
MM
/
DD
/
YYYY
Grade
Student Email
Student Cell Phone #
Address + City, State, Zip
Medical Insurance Provider
Policy #
Mother's Name
Mother's Email
Mother's Cell #
Father's Name
Father's Email
Father's Cell #
Emergency Contact *
Emergency Contact Cell # *
Emergency Contact Email
Physician/Practice
Office Phone #
Code of Conduct: We expect each student to conform to these rules of conduct, both for weekly gatherings and on retreats: No possession or use of alcohol or drugs; No fighting, weapons, fireworks, or explosives; Participation with the group is expected; Respect property; Respect one another, staff, and adult leaders; Respect and comply with event schedules; Students who fail to comply with these expectations will review and renew conduct standards with a leader. Parents will be notified, and students may be sent home at their parents’ expense. *
Required
Medical History: If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your student is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Include names of medications and dosages that must be taken. Email any necessary details or documentation to micah@apostlescolumbia.org
For your student’s safety, and our knowledge, is your student a
Clear selection
Does your student have allergies to
Does your student suffer from, has ever experienced, or is being treated for any of the following:
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Church of the Apostles and its staff/volunteers of any liability against personal losses of named child. *
Required
Activity Permission: Activities may include, but are not limited to: Riding in leader-driven car, physically active group games (dodgeball, tag, volleyball, etc), swimming in cold water, exploring outside, and close proximity to campfires. Note: If you desire to limit your child’s participation in any event, please submit your wishes in writing to the church youth director prior to that event. *
Required
Photo and Media Release: This release form grants Church of the Apostles the right to use your student’s image, voice, and associated media (for example, sounds, singing, transcripts, etc.) for the purposes of marketing materials, and/or church use. These media elements may be utilized on social media, Church of the Apostles website, in videos/films, and in other audio‐visual mediums. If you are signing for another person (for example because they are underage), you also agree that you have the legal right to agree for them. [Type full parent name as electronic signature to voluntarily agree to this release.]
OR: NO Photo & Media Release
Student Signature: I, the student, have read the code of conduct, the above evaluation of my health, permission statement to participate in youth group activities, and photo release. I agree to abide by the stated personal limitations and code of conduct. [Type full name and date] *
Parent/Guardian Acknowledgement: I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by Church of the Apostles. I/We understand that there are inherent risks involved in any ministry event, and I/we hereby release Church of the Apostles, its clergy, employees, agents, and volunteer workers from any and all liability for any injury, loss, damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires medical attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such persons free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our expense should s/he become ill or if deemed necessary due to conduct by the student ministry's staff member. *
Required
My student, ______________, has permission to attend and participate in all youth activities sponsored by Church of the Apostles during the 2023/2024 school year. [Type Student Full Name, Parent Full Name, and Date] *
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