701 Beach Drive NE

St. Petersburg, FL 33701

727.822.2031 Fax: 727.894.2971

YOUTH PERMISSION FORM

Effective Dates: 9/1/09 to 8/31/10

Youth Name _________________________________ Age _____ Birthday ___________

Grade________ ˆ Female ˆ Male Email ______________________________________
Address ______________________________ City__________________ Zip _________
Phone _______________________________ Cell ______________________________

Mother’s Name ______________________________

Phone ___________________ Office ___________________ Cell __________________
Address (if different from above) __________________________________________________

Father’s name ________________________

Phone ___________________ Office ___________________ Cell __________________
Address (if different from above) __________________________________________________

Emergency Contact: _______________________

Phone ___________________ Office ___________________ Cell __________________

CONSENT TO EMERGENCY MEDICAL CARE

I hereby give my consent to any physician, emergency personnel and healthcare facility to provide
medical care to my child, ___________________________________________, in the event of an
emergency. I give consent to transport by ambulance if the situation warrants it. In addition, I agree to
be financially responsible for any medical expenses that are incurred in the treatment of my child.
Physician ________________________________ Phone _________________________________
Dentist _________________________________ Phone _________________________________
Allergies ________________________________________________________________________
Date of last DPT or Tetanus shot ____________________
Are there any other medical or emotional considerations that we should be aware of?
_______________________________________________________________________________

Medical Insurance Company ____________________________

Policy Number ____________________________________
 AUTHORIZATION TO PARTICIPATE IN YOUTH ACTIVITIES
RELEASE AND INDEMNIFICATION
I understand that there are inherent risks involved in any youth activity or event in which the Youth
participates, whether on or off the premises of First Presbyterian Church of St. Petersburg (Church).
On behalf of the Youth desiring to participate in Church sponsored activities for Youth, held on or off
Church premises, and in consideration of the Youth's participation in and being provided transportation
to said activities, the undersigned parent or guardian hereby releases Church and its ministry staff,
employees, members, volunteers or agents from, and agrees to indemnify, defend and hold harmless
Church and its ministry staff, employees, members, volunteers or agents from and against any and all
demands, claims, causes of action (including any personal injury or damage to property), fines,
penalties, damages (including consequential damages), liabilities, judgments, and expenses (including
without limitation attorneys' fees) arising from or in connection with the Youth's participation in
Church-sponsored activities whether conducted on Church premises or off the Church's premises. The
undersigned voluntarily and knowingly executes this release and indemnity agreement on behalf of the
Youth with the express intention of extinguishing the rights and obligations designated herein. I also
agree to permit supervision and transportation of the Youth in accordance with Church policy.
Additionally, unless I expressly deny the Church authority to use photographic or other digital
representations of the Youth, I grant my consent to use the same by the Church for any purpose,
including display on Church authorized web sites.

COVENANT OF CONDUCT
In all meetings, retreats or other events under the sponsorship and/or guidance of the Church, I am
representing the Christian community and I am responsible for my actions. I understand the following
guidelines will be followed:
1. No use or possession of illegal drugs, alcoholic beverages and tobacco.
2. All conduct will respect property, one another, staff, adult leaders, schedules and event rules.
3. No fighting, weapons, fireworks, lighters or explosives.
4. No offensive or immodest clothing.
5. Participation with the group and in the activities is expected.
I, the above named Youth, understand the above Covenant of Conduct and I agree to abide by it to the
best of my ability.
Youth Signature ________________________________________ Date ____________________

We (I), as parents (guardians), understand all three parts of this agreement. If the Youth disregards
the Covenant of Conduct, a serious attempt to contact all the above phone numbers will be made and
plans to pick up the Youth will be arranged. If we (I) are unavailable for contact or refuse to pick up the
Youth, the current most available transportation carrier will be used at my expense to return the Youth
home.
Parent (Guardian) Signature_______________________________ Date ____________________
Print Name ____________________________________________

STATE OF FLORIDA, COUNTY OF ___________________________

The foregoing instrument was sworn to and subscribed before me this ____ day of ____________,
_____, by _____________________, who is personally known to me or who has produced
_________________________ (type of identification) as identification.

NOTARY PUBLIC, STATE OF FLORIDA