JMP 8/25/2015Youth Medical Release Form

JMP 8/25/2015Youth Medical Release Form St. John Youth Ministry Summer Camp Calling all Youth Entering 6 – 9th Grade!

Get ready for a truly enlightening experience this summer! Join us as we learn about Jesus and how we can be a beacon of light shining brightly for others through games, team building activities, crafts, service and prayer. When: June 27 – June 29, 12:30 p.m. to 5:30 p.m. and June 30, 12:30 p.m. – 9:30 p.m. Where: St. John Education Center Cost: $50 per youth – Children of Volunteers are Free! *If the cost is an issue please call Josh Plandowski. We will never turn someone away because they cannot afford it!

The camp will have a variety of activities on each day!

 Monday, June 27 – Field Day at Guardian Angels Parish  Tuesday, June 28 – Rock Climbing at Rockquest Climbing Center  Wednesday, June 29 – Day of Service (Locations TBA)  Thursday, June 30 – Laser Tag & Go-Karting at The Web

Each day will include prayer, games, small group discussions, snacks and an outing!

Want to help? Assistance is needed!

Plenty of volunteers will be needed to run this camp! We will need adult drivers for outings, snack coordinators, group leaders and more. High school teens are encouraged to join the camp as volunteers! High school students can volunteer to help with games, prayer, snacks and as small group leaders. If you have any questions please contact Josh Plandowski at [email protected]

Volunteer Opportunities (Choose up to 3 ways you would most like to help)

____ Games ____ Driver ____ Snacks ____ Prayer ____ Group Coordinator ___ Group Leader

Are you or your teens volunteering for Vacation Bible School? We have a discount for that! If you or your teens are assisting with VBS and your teen attends our camp, the cost of the Jr High Summer Camp will only be $25.00! If you have any questions about this discount please let us know! JMP 8/25/2015Youth Medical Release Form St. John Youth Ministry Summer Camp ARCHDIOCESE OF CINCINNATI RELEASE AND INDEMNIFICATION AND MEDICAL POWER OF ATTORNEY (Completed by Parent or Guardian, Please Print) This Permission, Release, and Medical Power of Attorney Form will cover all onsite and offsite activities of St. John Youth Ministry Summer Camp, and including transportation, from the date signed through June 30, 2016. 1. I, the lawful parent or guardian of ______(the “child”), give permission for my child to participate in all St. John Youth & Young Adult Ministry activities, and release from all liability and indemnify the Archbishop of Cincinnati (“the Archbishop”), both individually and as trustee for the Archdiocese of Cincinnati and all parishes within the Archdiocese, and their officers, agents, representatives, volunteers, and employees from any and all liability, claims, judgments, cost or expenses, including attorney fees, arising out of any injury or illness incurred by my child while participating in or traveling to or from the activity. 2. I agree to instruct my child to cooperate with the Archbishop or his agents in charge of the activity. 3a. I appoint the Archbishop or his agents who are acting as leaders of the activity as my attorney in fact to act for me in my name and my behalf, in any way that I would act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity or related travel: (i) To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our attorney shall deem necessary or appropriate for the best interest of the child. (ii) I understand that the agents of the Archbishop will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my child. 3b. The powers and authority granted herein may be revoked by me by written notice delivered to the Archbishop or his agents who are then acting or who have previously acted hereunder. Without such written notice, this power of attorney shall not be affected by my disability, incapacity or adjudicated incompetence. This power of attorney shall lapse automatically at the end of above said time period. 4. I agree that the Archbishop or his agents may use my child’s portrait, photograph, or video including digitally or electronically, for promotional purposes, office functions, websites, & social media,and hereby release the Archbishop and his agents from any liability resulting from such use. I have carefully read this statement, and my signature acknowledges that I fully understand its content and meaning.

______/____/____ Print Parent/Guardian Name Signature of Parent or Guardian Date

Youth Name______Birthdate___/___/___ Grade____

Home Phone ______Cell Phone ______Parent’s Email______

Home Address______City/State______Zip______

Medications______Allergies/Disorders/ Chronic conditions (e.g. epilepsy, ADHD, diabetes)______

Medical Insurance Company______Member Number______

Member’s Name______*Member’s Social Security #______

Child’s Doctor______Phone______*Child Soc. Security # ______

* Social Security Number is optional. Please note that some hospitals WILL NOT treat without it.

Emergency Contact______Relationship______Phone______Activity Information Event: St. John Youth Ministry Summer Camp Event Contact: Josh Plandowski (Youth Minister) Work: 513-777-6433 Cell: 937-405-9970 Meeting Time: 12:30 p.m. – 5:30 p.m. Mon-Wed, 12:30 p.m. – 9:30 p.m. Thurs. Activities Involved: Field Day Games, Rock Climbing, Laser Tag, Go-Karting, Small Group Activities, Dodgeball, Flashlight Tag, Arts & Crafts, Service & Prayer Cost:$50.00 (Scholarships Available!) Activity Locations St. John the Evangelist (9080 Cincinnati Dayton Rd, West Chester, OH 45069) Guardian Angels Parish (6531 Beechmont Avenue, Cincinnati, OH 45069) Rockquest Climbing Center (3475 East Kemper Rd Sharonville, OH 45241)JMP 8/25/2015Youth Medical Release Form The Web (7172 Cincinnati Dayton Rd, West Chester, OH 45069) Service Projects (Locations TBA after registration due date)