Covenant & Consent for Parents & Youth (Quest Lock-In)

Covenant & Consent Form - 2024 Middle and High School Lock-In (for PARENTS and YOUTH)

Covenant and consent for retreat, release waiver and indemnification forms

2024 Middle and High School Quest Lock-In- The Ship

To be completed by PARENTS and YOUTH. Please complete the forms no later than April 17th prior to coming to St. John's Cathedral.

Youth Participant's Full Name

Birth Date(Required)

Grade as of Fall 2024

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

Youth Participant's Preferred Pronouns

he/him/his

he/them

she/her/hers

she/them

they/them/theirs

other

Address

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

Consent(Required)

I agree

I/we understand that certain rules of conduct have been established for all participants during this retreat and I/we assume responsibility for the youth’s actions during this retreat and the youth’s compliance with the rules. I/we 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/we will accept a telephone call concerning the youth’s actions and behavior and I/we further understand, agree that I/we will bring the youth home at my/our expense or effort.

I/we further understand and agree that the youth will travel by private vehicle or rented vehicle to get to the retreat, and I/we 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/we 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/we 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.

We, parents/guardian, and youth, understand that for a successful, fun, and safe lock-in everyone must participate fully and with a good spirit. Therefore, we agree to the following pledge, as shown by our signatures below:

I (youth) will participate fully in each activity and task throughout this trip. I will show respect for the adult leaders, for my peers, for 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 youth, 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. Parents…NO NEWS IS GOOD NEWS! Please refrain from asking your child to call or text home during this retreat, so they can be fully present with the group.

I/We understand that if I am unable or unwilling to participate in a safe and constructive manner, my parents/guardians will be contacted to come pick me up from this trip, at their expense or effort.

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

Youth’s names will not be listed or captioned with their photo on any public site. 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' individual FaceBook pages

Yes

On churches' public websites

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

Parent/Guardian 1 Name:(Required)

Parent/Guardian 1 work phone:(Required)

Parent/Guardian 1 cell phone:(Required)

Parent/Guardian 2 Name:

Parent/Guardian 2 work phone:

Parent/Guardian 2 cell phone:

Emergency Contact (other than parent/guardian):(Required)

Emergency Contact Phone Number(Required)

Relationship to participant

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):

Does your youth take prescription medication on a regular basis?(Required)

Yes

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:

Does your youth take an over-the-counter medication on a regular basis?(Required)

Yes

If yes, what over-the-counter medicines:

Ibuprofen (Advil, Motrin) / Acetaminophen (Tylenol) **We will not give youth aspirin.

Benadryl/Claritin for allergic reaction

Ointments such as: Cortisone cream, Aloe Vera, Antibiotic Cream

Antacids, Imodium, Pepto Bismal, Milk of Magnesia

Other (please specify)

(check all that are permitted)

Permission to give over-the-counter medicines:

**Youth will be reminded to use sunscreen and insect repellent but are ultimately responsible for the application of both. Severe sunburn can be cause for youth to be sent home as it is a medical condition with inherent risks.

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 your youth needs a reminder to take their medications, please indicate with any notes here:

IF YOUR CHILD STARTS 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 me as soon as possible, and that efforts to contact me 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 Company Information

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

Please provide your youth leader with a photocopy of your insurance ID card.

Signature Page

Parent/Guardian 1 Name(Required)

First Last

Date(Required)

Parent/Guardian 2 Name

First Last

Date

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 - 2024 Middle and High School Lock-In (for PARENTS and YOUTH)

2024 Middle and High School Quest Lock-In- The Ship

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

Emergency Contacts

Medical Information and Authorization

Permission to give over-the-counter medicines:

Instructions about medications

IF YOUR CHILD STARTS 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 your youth leader with 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 - 2024 Middle and High School Lock-In (for PARENTS and YOUTH)

2024 Middle and High School Quest Lock-In- The Ship

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

Emergency Contacts

Medical Information and Authorization

Permission to give over-the-counter medicines:

Instructions about medications

IF YOUR CHILD STARTS 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 your youth leader with a photocopy of your insurance ID card.

Signature Page

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