Covenant & Consent for Adults (Quest) | The Episcopal Church in Colorado

Covenant & Consent Form (for ADULT PARTICIPANT - 2024)

Covenant and consent for retreat, release waiver and indemnification forms

2024 Quest Lock-In- The SHIP

To be completed by ADULTS. Please complete the forms by April 17st and prior to coming to St John's Cathedral.

Adult Participant's Full Name

Adult Participant's Preferred Pronouns

he/him/his

he/they

she/her/hers

she/they

they/them/theirs

other

where we can send you information and updates about this retreat

Phone

where we can contact you (if necessary) to obtain information related to this retreat

Is this a home, work or cell/mobile number?

home

work

cell/mobile

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Consent(Required)

I agree

I understand that certain rules of conduct have been established for all participants during this retreat and I assume responsibility for MY youth’s actions during this retreat and the youth’s compliance with the rules. I agree that, in the event the youth violates the established rules for youth during this trip:

In the event of repeated violations or a serious violation of the established rules by the youth, I will work with the main youth leader and event coordinator to call the youth’s parents concerning the youth’s actions and behavior and I further understand, agree that I will work with the event coordinator and the youth’s parents to send the youth home at the parent’s expense or effort.

I understand that I am responsible for the youth attending the retreat. Should there be any kind of emergency regarding my youth participants requiring them to need to go to an urgent care or emergency room I or another adult from my group will need to accompany the youth and will take all medical forms with me to give to the medical professionals.

I understand and agree that I may travel by private vehicle or rented vehicle to get to the retreat, and I hereby consent thereto and specifically: (1) waive any and all claims of any sort or nature I/we may have against the owner and/or driver of any such private or rented transportation for any personal injury, bodily injury or death and for any property damage, regardless of the cause thereof, and (2) agree to hold harmless and indemnify the owner and/or driver of any such private transportation from any and all claims or demands of any sort or nature which may be asserted by or on behalf of the youth for any personal injury, bodily injury, death or property damage, regardless of the cause thereof.

I waive any claim against The Episcopal Church in Colorado, and the Design Team, their sponsors, agents, servants, volunteers and employees and hereby release them from any responsibility and liability for any personal or bodily injury, death or property damage that my child may sustain during the above listed activity. I/we agree to indemnify, save and hold the church, its agents, servants, volunteers, and employees, harmless from any claim, demand or cause of action of whatsoever nature or kind asserted by or on behalf of the youth for any personal or bodily injury, death or property damage sustained by the youth during the trip/event and the youth’s participation therein.

I assume all liability for and agree to save, indemnify, defend and hold The Episcopal Church in Colorado, and Design Team, their agents, servants, volunteers, and employees, harmless from any and all claims or demands of any sort or nature for damage or injury to persons or property caused by the acts or neglect of the youth.

Conduct Covenant(Required)

I agree.

I understand that for a successful, fun, and safe service trip everyone must participate fully and with a good spirit. Therefore, we agree to the following pledge, as shown by our signatures below:

I will participate fully in each activity and task throughout this trip. I will show respect for the adult leadersfor myself, and for the buildings, vehicles, and materials around me. This includes listening carefully to instructions and safety procedures and following them, as well as asking questions anytime I’m not sure what I should be doing.

I understand that there will be an 8-hour ‘lights out’ sleeping time every night and that I am to be in my bed and quiet during that time with my phone turned off.

I understand there is a strict no substance use policy. I will not bring, consume, or use any illegal substances, alcohol, tobacco products, including vape products, while on this trip. If I am found doing so, I and my parents understand they will be contacted to come pick me up from this retreat.

I understand there is a strict no bullying policy. I will treat my peers and leaders with kindness and respect. My language and actions will model Jesus’s love for all of us. I will respect the unique identity of each person I interact with during this retreat.

Should I have a misunderstanding between myself and another person, I will first try to work it out with that person. If I need help, I will talk to an adult leader.

It is my responsibility to eat the healthy food I’m offered (medical dietary restrictions will be met), stay hydrated, use sunscreen whenever I will be outdoors, take my prescribed medication(s), and otherwise keep myself healthy. If I am feeling unwell it is my responsibility to let an adult know right away.

I understand my cell phone may be used for taking pictures, listening to music at approved times, and in case of an emergency. I agree that I will never post or tag another person’s photo on any social media without that person’s express permission. I understand that if I use my cell phone when I should be participating in worship, programing, or in any other way interacting with the group I will be given a warning, and if I persist in inappropriate usage my phone will be held by an adult leader for the remainder of the trip.

I understand and agree to follow the Safe Church policies at all times.

Photo Waiver - I give permission to use my image in the following formats:

Please don’t hesitate to be specific; we fully understand that while some families aren’t worried about their children’s photos being ‘out there,’ for others it is a serious concern and possible safety issue. We want to honor your preferences at all times.

In-house displays for participating parishes

Yes

On churches' public websites

Yes

On churches' individual FaceBook pages

Yes

On Diocesan materials including but not limited to the Colorado Episcopalian, the Diocesan website, the Cathedral Ridge website, and the Cathedral Ridge Facebook page and Instagram.

Yes

Emergency Contacts

Name (person 1):(Required)

cell phone (person 1):(Required)

Name (person 2):

cell phone (person 2):

Medical Information and Authorization

Doctor's Name(Required)

Doctor's Phone Number(Required)

Allergies (include all food, environmental, insect or medicine, allergies and symptoms of exposure):

Prescription Medications to be taken during this retreat: Medicine 1:

List each medication and include the condition medicine is prescribed for, the dosing amount and instructions and date and time of last dose before leaving for this retreat (ex. Metformin for Diabetes 2, 1 tablet twice a day with breakfast and dinner. Last dose taken today at breakfast):

Medicine 2:

Medicine 3:

Medicine 4:

Medicine 5:

Instructions about medications

All medications, either prescription or over the counter will be collected by your youth leader before you leave for the retreat. Please put your youths’ medications in a zip lock bag clearly marked with their name and give them to your youth leader before they leave. Upon arriving at Cathedral Ridge, all medications will be collected by our trip nurse and kept in a secure location. Each day youth will come to the nurse to take their medications. A log will be kept of all medication taken by the youth.

IF YOU START A NEW MEDICATION BETWEEN NOW AND THE RETREAT, PLEASE MAKE SURE WE KNOW ABOUT THE NEW MED, HOW AND WHEN TO DISPENSE IT, AND ANY POSSIBLE SIDE EFFECTS IT COULD CAUSE, THANKS!

Emergency Room or Urgent Care

In the event of an emergency, I understand that every effort will be made to contact my emergency contact as soon as possible, and that efforts to contact my emergency contact will continue even as care or treatment is administered. If needed, which is your preference: Urgent Care or Emergency Room. An effort will be made to meet this request if possible.

Please make a selection:

Emergency Room

Urgent Care

I hereby authorize the adult leader(s) named below to act as agent for me and to seek and consent to any medical, dental, or surgical evaluation and treatment deemed necessary by a licensed medical professional.

Adult Leader permitted to act as my agent:

Insurance

Participant's Name

First Last

Insurance Information (with insurance coverage)

I/We have medical insurance coverage for the above-named participant.

Insurance Information (without insurance coverage)

I/We have acknowledge that the above-named participant is not covered by any medical policy and understand that I/we are responsible for all costs.

Insurance Company Information

Include: Name of Company, Policy # Street Address, City/State/Zipcode, Name of Policyholder Group #

Please provide a photocopy of your insurance ID card.

Signature Page

Your Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Untitled

Post Title

Name

First Last

Mike O2024-03-28T11:22:53-06:00
Message from Bishop Kym: Wednesday, April 3

Message from Bishop Kym: Wednesday, April 3

Covenant & Consent Form (for ADULT PARTICIPANT - 2024)

2024 Quest Lock-In- The SHIP

Photo Waiver - I give permission to use my image in the following formats:

Emergency Contacts

Medical Information and Authorization

Instructions about medications

IF YOU START A NEW MEDICATION BETWEEN NOW AND THE RETREAT, PLEASE MAKE SURE WE KNOW ABOUT THE NEW MED, HOW AND WHEN TO DISPENSE IT, AND ANY POSSIBLE SIDE EFFECTS IT COULD CAUSE, THANKS!

Emergency Room or Urgent Care

I hereby authorize the adult leader(s) named below to act as agent for me and to seek and consent to any medical, dental, or surgical evaluation and treatment deemed necessary by a licensed medical professional.

Insurance

Please provide a photocopy of your insurance ID card.

Signature Page

Mike O2024-03-28T11:22:53-06:00Message from Bishop Kym: Wednesday, April 3

Message from Bishop Kym: Wednesday, April 3

Covenant & Consent Form (for ADULT PARTICIPANT - 2024)

2024 Quest Lock-In- The SHIP

Photo Waiver - I give permission to use my image in the following formats:

Emergency Contacts

Medical Information and Authorization

Instructions about medications

IF YOU START A NEW MEDICATION BETWEEN NOW AND THE RETREAT, PLEASE MAKE SURE WE KNOW ABOUT THE NEW MED, HOW AND WHEN TO DISPENSE IT, AND ANY POSSIBLE SIDE EFFECTS IT COULD CAUSE, THANKS!

Emergency Room or Urgent Care

I hereby authorize the adult leader(s) named below to act as agent for me and to seek and consent to any medical, dental, or surgical evaluation and treatment deemed necessary by a licensed medical professional.

Insurance

Please provide a photocopy of your insurance ID card.

Signature Page

Mike O2024-03-28T11:22:53-06:00
Message from Bishop Kym: Wednesday, April 3