Pop Up Youth Covenant

Participant Name *

First Name Last Name

Grade

Special Needs/Dietary Restrictions

Congragation

Parent/Guardian Name

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number

E-mail

Emergency Contact

First Name Last Name

Emergency Phone

Area Code Phone Number

Pop Up Youth Ministry is an intentional Christian community. In such a community, the behavior of all participants reects the faith we share in Jesus Christ our Lord. Therefore, it is expected that:

1. For reasons of continuity and group building, all participants are needed for the entire event. Therefore, no one will be allowed to attend only a portion of the event.

2. For reasons of safety and accountability to parents, participants will remain throughout the event, and the event leaders will be advised if leaving the site becomes necessary.

3. All registrants - both youth and adults - will participate fully in all activities at the event.

4. Absolutely no alcohol or other drugs (other than prescribed medication) will be brought to or used at the event.

5. Stereos, TVs, iPods, etc. WILL NOT be brought to the event.

Parent/Guardian Consent

I hereby give permission for my son/daughter to participate in all activities. Further, I give permission for use of photos/videos of my son/daughter to be used in promotion unless noted. My son/daughter will follow the rules and directions of the staff.

Insurance Information

Medical Policy Carrier

Subscriber Name

Policy Number

Authorization for Treatment

I hereby give permission to the medical personnel selected by the event leaders to order x-rays, routine tests, and necessary transportation for my son/daughter. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the event leaders to secure and administer treatment, including hospitalization for my son/daughter as named above.

Participant Signature

First Name Last Name

Parent/Guardian Signature

First Name Last Name