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Information, Permission & Medical Form
Name of Youth: _____________________________________________________
Birthdate: _____________________ T-Shirt Size: _________
Name(s) of Parents/Legal Guardians: ______________________________________________________________________ Home Address: _____________________________________________________________________________________________
Home Phone: ________________________________
Parents’ Email: _________________________________________
Mom’s Cell Phone: _______________________________ Dad’s Cell Phone: ___________________________________ Alternate Emergency Contact Person: _____________________________________________________________________ Phone Number: ________________________________________________
Insurance Company & Phone Number: ____________________________________________________________________
Name of Policy Holder: ___________________________________ Policy Number: ______________________________ Current Medications:
I, _____________________________________, hereby give my permission for __________________________, to
participate in all First Presbyterian Church Youth Ministry activities, both on and off the church grounds
I also give my permission that the above named youth can ride on the church bus, in the church
suburban, in a leader/adult chaperone’s private car, rental vehicle driven by adult leaders, or other
commercial transportation for youth activities, events, and trips.
In the event of a medical emergency and if I cannot be reached, I also authorize a representative
of First Presbyterian Church to retain or acquire medical care and treatment on the behalf of the above
named youth. I authorize any hospital, clinic, physician, doctor, nurse, or technician to furnish the above named youth with any medical care and treatment necessary.
I further ____ authorize/ ____ do not authorize the youth pastor and/or other adult advisors to give
my youth (please circle any that apply): Tylenol, Ibuprofen, Pepto-Bismol, Imodium, Tums, or Benadryl
as the need arises during youth activities, events and trips.
And I hereby release and hold harmless First Presbyterian Church of Sumter, SC, its staff, its
session, and volunteer adult advisors, as well as staff and volunteers of all assisting groups and vendors,
from any and all liability arising from my child’s participation in these events.
Code of Conduct & Covenant
Along with the adult advisors and other youth, I agree to conduct myself in a Christian manner. I promise to respect God, respect myself, respect other people, respect property, and respect
God’s creation. To this end, as a willing participant in Youth Group & Trips of First Presbyterian Church of Sumter, SC for the school year of 2013-2014 and the summer of 2014, I
1. I will actively and enthusiastically participate in all activities and events as I am able for the
duration of each activity or trip that I attend. I will welcome every individual as a member of our
community, whether they are from our church, are a guest, or are the member of another church.
2. At all times, I will behave in a responsible Christian manner, respecting other people and the
authority of the Youth Pastor and adult advisors, remembering that I am a representative of my
family and of First Presbyterian Church. I will also respect and abide by the decisions and plans
made by the Youth Pastor and adult advisors.
3. I will operate by the buddy system, always keeping at least one other youth with me at all
times. 4. I will remember that as a member of First Presbyterian Church youth group, all of my actions
will reflect upon my church family. I will not use or possess alcohol, tobacco, fireworks, firearms,
or illegal drugs while participating in Youth Group. I will also refrain from any inappropriate
5. I will abide by the FPC Youth Group House Rules. I will abide by the rules and regulations
established by any group with which we are traveling.
6. I understand that if I am unable to behave in any way the Youth Pastor and/or adult advisors
determine responsible and respectful or violate any section of this covenant, my actions or
inactions could result in disciplinary measures including the immediate end of my involvement in any trips and youth programming. All expenses incurred during disciplinary actions, including
special travel arrangements, will be the responsibility of my family.
7. I understand that any pictures that may be taken during this or any other First Presbyterian
Church event may be posted in the newsletter or on the website, or used for general publicity
I have read the First Presbyterian Church’s Youth Group Code of Conduct & Covenant,
and I promise to God and the community to live by this covenant.
I have read this covenant over with my youth, and we both understand & agree to it.
Anesthésie et analgésie chez le toxicomane (1) Unité de traitement de la douleur - DAR CH de Mâcon Boulevard Louis Escandre 71018 MACON [email protected] (2) SAR hôpital Foch – SURESNES 75 Paris [email protected] L'accueil d'un patient toxico-dépendant en milieu chirurgical reste toujours difficile, mais l’évolution du regard porté sur les addictions a cependant profondéme
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