Parental/Guardian Consent and Liability Waiver/Medical History

Code of Conduct

(Please print and sign where designated)

Participant’s Name: _________________________________________________

Home Address: _______________________________

City: ____________________  State:        Zip: ____________

Date of Birth:     /____/______  Age:       

Parent/Guardian: ___________________________________________________________________

Home Phone:      _____________________Cell:      ___________________

Church Parish: _____________________________________________________

Emergency Contact Name: ___________________________________________________________________

 Phone:      ___________________

** Important :   To be filled out by parent or guardian for youth under 18 years of age

I/We grant permission for my/our child to participate in the James P. Lyke Conference and all planned activities.  I/We agree on behalf of me/us, my/our child named herein, and my/our heirs, successors and assigns to release, defend, hold harmless and indemnify the Diocese of Charleston, the Lyke Conference, the sponsoring offices, their employees, agents or representatives, associated with the scheduled activities for any claims of property damage or personal injury arising from the negligence and/or intentional act of my/our child except for any such claims caused by the negligence or intentional acts of the released parties, their employers, agents or representatives.

Parent/Guardian signature: _________________________________________________

Parent/Guardian signature: _________________________________________________

MEDICAL FORM

Name:      ___________________     ___________________

Daytime phone:      ___________________

Medical Insurance Carrier:      ___________________     ___________________Group#     _______

Name of insured parent:      ___________________     ___________________ID#:      __________

HEALTH HISTORY

What is your child’s health status now?  ___ Excellent     ___ Good     ___ Fair

Date of last tetanus toxoid immunization?     /____/______

Is your child taking any prescription medication?  ___ Yes  ___ No

If yes, explain: _________________________________________________________________________________

______________________________________________________________________________________________

Is there any medical matter the Lyke Conference should be aware of? ___ Yes  ___ No

If yes, explain: _________________________________________________________________________________

______________________________________________________________________________________________

CODE OF CONDUCT

To be signed by youth and witnessed by parent

We _______________________________ and   _______________________________, parent and child, acknowledge and accept in writing that participation in the James Lyke Conference youth track is based upon mutual trust, respect for others and adherence to the spirit and the specifics of the standards of the Code of Conduct which are:

• That the use or possession of alcohol, illegal drugs, fireworks, firearms or any other kind of weapon is prohibited
• That the use or possession of tobacco in any form is prohibited
• That leaving the conference site without consent from my chaperone is prohibited
• That the use of inappropriate, abusive language or inappropriate behavior (sexual or otherwise) is prohibited
• That disrespect of elders or peers and disrespect of property will not be tolerated

Attending this conference is a privilege and the participants are encouraged to enter fully and cooperatively in the activities of the Lyke Conference.  Any violation of this Code of Conduct will result in expulsion from the Lyke Conference.  Parents or emergency contacts will be notified immediately to pick up their child.

I have read this agreement and will adhere to this Code of Conduct during my participation at the James P. Lyke Conference 2006.

Youth’s signature________________________________________________________________________

Parent/guardian Witness___________________________________________________________________

**. Issue form for all participants 17 years of age or younger.

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