Registration, Medical Release, and Permission Form for Episcopal Diocese of Louisiana Saturday at Solomon for Grades 9-12, November 20th, 2021
Rev. Jane-Allison Wiggin, Diocesan Youth Event Coordinator, may be reached at jwiggin@edola.org or 504 295 1375, for scholarship inquiries and other event questions

For DYLC adults on staff, please put n/a when necessary to complete your registration
Sign in to Google to save your progress. Learn more
Email *
How will you pay? 1) For credit card/paypal, use the link on the Solomon Episcopal Conference Center event page OR 2) You may bring cash or check for $30 (per person) made out to SECC 3) OR To request financial aid, please check the box below and Mother Jane-Allison will be in touch to assist. *
Parent Email Address *
Parent Name
Best number(s) to call in case of an emergency *
Home Address *
Youth Name *
Birthday *
MM
/
DD
/
YYYY
Grade for 2021-2022 School year *
School *
Youth Email (different from parent email or n/a) *
Youth Phone Number (if none put n/a) *
Church *
Dietary restrictions/allergies *
Doctor's name and contact information *
Current medications *
Allergies to any medications *
Should your child’s outdoor activities be restricted for any reason? Do you have any concerns? *
Should your child be allowed to swim in the pool, with a lifeguard on duty? *
This is an outdoor event at the Solomon Center covered pavilion, pool area, volleyball court and disc gold course. All staff and youth attending must be vaccinated to attend. Thank you in advance for telling your child that wearing a face mask while indoors or whenever within 6 feet of another person is expected. *
Required
Permission to collect your teenager's medications, bagged and labeled, upon arrival AND to distribute at breakfast, lunch, and dinners as needed. PLEASE SEND ALL PRESCRIPTION MEDICATION IN PRESCRIPTION CONTAINERS. Permission to give over the counter medication (tylenol, benadryl, etc) if needed. No youth self-medicate while on the retreat. *
Required
Photo Release: Permission to use photographs of youth from this event on the diocesan website or social media promotions. *
PARENT PERMISSION: My child has my permission to attend youth events sponsored by The Episcopal Diocese of Louisiana. This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named youth. Any healthcare information provided to the Church may be shared with any physician, caregiver, emergency medical provider, staff, or others in the discretion of the Church. The undersigned parent/guardian consents to this use of the personal healthcare information of the minor. 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 the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its Priests, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our youth’s involvement. In the event that he/she is injured and requires the 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 person 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/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the program coordinators. *
Required
RULES OF CONDUCT FOR YOUTH: No possession or use of alcohol, drugs, or tobacco. No fighting, weapons, fireworks, or explosives. No sexual activity. No hate speech. Students who fail to comply with the above expectations will be sent home at their parents’ expense. No students should drive a car or ride in a car during a youth event unless it is part of the event program. No youth should possess a lighter at a youth event. No youth should wear offensive or see-through clothing or use offensive or sexually explicit language. Participation with the group activity or event is expected during the entire event, participants should be at all “big group” and “small group” activities associated with the event. All participants are only allowed in their own room or living space or in large group space during all youth events. It is NEVER appropriate for a youth to be alone with an adult behind a closed door/out of sight from others. All staff and participants should respect personal property of the participants as well as the physical property at the even space. Everyone at a youth event should respect one another, the staff, and adult leaders at all times. Students who fail to comply with the above 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 permission to participate in youth group activities. I agree to abide by the stated personal limitations and code of conduct. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Edola.org. Report Abuse
Google Forms