BELONG

YOUTH REGISTRATION

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Youth Medical Release & Code of Conduct Form

Event:*
Participant's Name*
First Last
Parent/Guardian Name*
First Last
Parent Phone Number*
Grade in school*
Home Church (if any)*
Code Of Conduct:
1. I will not smoke, drink alcoholic beverages, or use illegal substances, nor will I have in my possession any of the same during this activity.
2. I will cooperate with the scheduled program of activities.
3. I will show respect to myself and others at all time.
4. I will not engage in any inappropriate public display of affection.
5. I will not engage in any sexual activities.
6. I understand that if I do not adhere to this code of conduct, it may result in a warning, calling home, and or expulsion from the event. I understand this means my parent/guardian will be called and they will be required to provide transportation home for me from the event at that time.
Consent:*
I, the participant, have read and agree to the Code of Conduct.
Emergency Contact #1 Name*
First Last
Emergency Contact #1 Phone*
Emergency Contact #1 Relationship*
Emergency Contact #2 Name*
First Last
Emergency Contact #2 Phone*
Emergency Contact #2 Relationship*
Please explain any restrictions or limitations affecting participation in the activity (be specific)
Any known allergies? If yes, please list and be specific*
Are any medications required? If yes, please explain*
Health Insurance Company*
Health Insurance Policy #*
AUTHORIZATION: Permission is granted for treatment of minor injury or illness. In the event of an emergency and I cannot be reached, I hereby give permission for the adult(s) in charge to seek professional medical help and transport my child.

I have ALSO read the above information regarding the code of conduct and I understand if my child is expelled from the event that I am required to provide transportation home at that time.
Parent/guardian: Please type in your name and date as authorization:*