JHM Pine Cove 2016 FORMS PACKET

Transcription

1 JHM Pine Cove 2016 FORMS PACKET Please turn in the following forms: 1. SSM Medical Form (4 pages) 2. SSM Responsibility Form (1 page) 3. SCC Exhibit A Form for JHM Pine Cove 2016 (2 pages) All students registering (online or by paper) will need to fill out and turn in these three forms by hand. If you registered online, you will only need to turn in these three forms and your insurance card (as long as your notarized forms are done). If you are registering through our office instead of online, then you will also need to pay by check or cash and turn in the SSM Event Registration form. Please feel free to call or Molly Jennerich to get help registering. Thank you! You may drop the forms off at our SCC Student Ministry Office (upstairs, building C) or them to Molly Jennerich at Mollyj@stonebriar.org.

2 Stonebriar Community Church Student Ministries Medical Information and Health Care Authorization Form Event: JHM PINE COVE 2016 Date of event: OCT 14 th 16 th, 2016 PARTICIPANT S INFORMATION Participant s Name (First, Middle, Last) Date of Birth Gender Age Full Address (Street, Apt#, City, State, Zip) Parent s or Legal Guardian s Names Participant s Social Security Number (SSN) Home Phone Number Father s Cell Phone Mother s Cell Phone Alternate Emergency Contact and This Person s Relationship to Participant (In case of an emergency if we cannot contact the parents, who should we contact?) Alternate Emergency Contact Phone Number HEALTH PROVIDER INFORMATION Participant s Doctor s Name Participant s Dentist s Name Participant s Orthodontist s Name Other Doctor s Name _ Doctor s Office Phone Number _ Dentist s Office Phone Number Orthodontist s Office Phone Number Other Doctor s Office Phone Number INSURANCE PROVIDER INFORMATION Participant is covered by insurance: Yes No For emergency treatment or hospitalization the social security number of the policy holder and student are required. Policy Holders Name Insurance Company Policy Number Policy Holder s Social Security Number Insurance Company Phone Number Subscriber or Group Number A photo copy of the front and back of your current medical insurance card will be required. I agree to provide a copy of the front and back of my insurance card or notify the SSM Staff if you do not have insurance at this time. Please initial here:

3 AUTHORIZATION This form and the information given are kept confidential. Select information may be shared with Student Ministry leaders to help minister and care for your child, and this form will be shared with emergency medical responders, clinic and hospital registration staff, and qualified care-givers staffing a clinic or hospital. By signing, I certify that this health history and information is correct and accurately reflects the health status of the participant to whom it pertains. I also certify that I have read every statement contained therein and that my initials, when indicated, have the same authorization as my signature. By signing, I hereby grant Stonebriar Community Church, its employees, and its agents, permission: 1. To photocopy this form. 2. To share information on this form with adults working with the participant. 3. To administer over-the-counter medications as they deem necessary. 4. To administer prescription medications as indicated in the medications section of this form. 5. To choose transportation to their chosen medical facility and physician for medical treatment of the participant. 6. To authorize the physician selected to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency. 7. To authorize the physician, if I cannot be reached in an emergency, to hospitalize, secure proper treatment for, and order injection, anesthesia or surgery for the participant. 8. To obtain a copy of the participant s health record from providers who treat the participant. 9. To talk to the attending health care providers about my child s health status. Signature: Date: MEDICAL HISTORY Date of Participant's Last Tetanus Booster: Other vaccinations are up to date: Info: The United States Centers for Disease Control have established immunization standards that are updated at least once a year. A child who is not fully immunized may be at greater risk of contracting communicable diseases, especially in environments where there are large gatherings of people, which can be prevented through immunization. Your initials certify that you understand and accept all of the risks to the participant related to the choice of not fully immunizing him or her. Please initial: Allergies: None Yes Participant is allergic to: Food Medication Environmental Factors (bee stings, hay fever, etc.) Please explain specifically what these allergies are, the symptoms when exposed to the allergen, and how the allergy is treated: Special Diet: Does the patient require special diet? Please explain specifically what the participant s special dietary needs or restrictions are: General Health History: Please circle Yes or No for each statement. Has/Does the participant: 1. Ever been hospitalized? Yes No 11. Had fainting or dizziness? Yes No 2. Ever had surgery? Yes No 12. Passed out/had chest pain during exercise? Yes No 3. Have recurrent/chronic illnesses? Yes No 13. Had mononucleosis ("mono") in the past 12 months? Yes No 4. Had a recent infectious disease? Yes No 14. If female, have problems with periods/menstruation? Yes No 5. Had a recent injury? Yes No 15. Have problems with falling asleep/sleepwalking? Yes No 6. Had asthma/wheezing/shortness of breath? Yes No 16. Ever had back/joint problems? Yes No 7. Have diabetes? Yes No 17. Have a history of bedwetting? Yes No 8. Had seizures? Yes No 18. Have problems with diarrhea/constipation? Yes No 9. Had headaches? Yes No 19. Have any skin problems? Yes No 10. Wear glasses, contacts, or protective eyewear? Yes No 20. Traveled outside the country in the past 9 months? Yes No Please explain any yes answer below, noting the number of the question with your explanation. If the participant has been outside the country, please name the counties that were visited and the dates of t

4 Mental, Emotional, Social Health Please check yes or no for each statement: Has the participant 1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder? Yes No 2. Ever been treated for emotional or behavioral difficulties or an eating disorder? Yes No 3. During the past 12 months, seen a professional to address mental/emotional health concerns? Yes No 3. Had a significant life event that continues to affect the students life? Yes No (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others?) Please explain yes answers, noting the number of the questions, and any prescribed treatment we will be expected to administer. We may contact you for additional information. MEDICATION INFORMATION The following medications may be on hand in the first aid kits that are sent along with church staff. Please circle no next to any medication you would NOT like us to administer to the participant: Acetaminophen (Tylenol) No Diphenhydramine Hydrochloride (Benadryl, antihistamine, oral) No Ibuprofen (Advil, Motrin) No Diphenhydramine Hydrochloride (Benadryl, antihistamine, topical) No Guaifenesin Cough Syrup (Robitussin) No Dextromethorphan Cough Syrup(Robitussin DM) No Medicated Throat Lozenges (Sucrets, No No Throat Lozenges (Halls, Ludens) Chloraseptic) Calamine Lotion No Antibiotic Cream (Neosporin) No Antacid (Tums, Maalox) No Aloe No Loperamide Hydrochloride (Imodium, antidiarrheal) No Alka-Seltzer Plus (a cold remedy with several medications for pain, No relief, fever reduction, nasal decongestion & cough control Bismuth subsalicylate (Kaopectate, Pepto- Bismol for upset stomach) No Medication is ANY substance a person takes to maintain and /or improve their health. This includes vitamins and other remedies. Please list any and all medications that the participant will be expected to take. Please send all medications in the ORIGINAL prescription bottle or package it came in or the original manufacturer s packaging or bottle. A prescription medication must have a prescription label with your child s name, doctor, and pharmacy clearly stated. Please send your child s medications along in the containers and place all of the containers in a Ziploc bag with your child s name clearly marked, preferably in large black letters. Your initials indicate that you understand all of the risks associated with the medications the participant is taking. Please Initial: Name of Medication Date Started Reason for Taking Dosage Amount To Be Given At PLEASE NOTE: Please DO NOT allow your child to have possession of any medications when sending them on a Student Ministries event, including any over-the-counter medications and/or home remedies except for those emergency items they must keep on their person such as an inhaler or epi-pen.

5 Is There Anything Else? Please provide in this space any additional information about the participant s health that you think would be important for us to know and may affect the participant s ability to fully participate in the event you are filling this form out for. NOTES (office use only):

6 Stonebriar Community Church Student Ministry Department - Responsibility Code In every area of life, there are parameters, rules, and regulations that we all must abide by. These codes offer ways in which the interactions and behaviors between people are governed and executed, so the interests of all are honored and maintained. For example, if we did not have the traffic laws that we do in the United States, our driving would be much more chaotic and subject to whim. It is no different in Biblical communities, in which the Scriptures are our guide and arbiter in the way we conduct our lives before our great and glorious God, and before all men and women we come to interact with on a daily basis. We are interested that the students in our ministry follow a high level of decorum and respect for authority, so that the treatment of others is above reproach and serves as a reflection of God s glory in our surrounding community. The following code of honor reflects our highest ideals and what we will strive for daily as a student community under the authority of Jesus Christ. General Code: 1. Respect others in the same way that you would like to be respected in return. 2. Respect all property owned by other parties that you will come to interact with as a part any SSM event, whether it is a building, furniture, or other equipment of any sort. 3. Respect the property of other students and adult staff. 4. You are responsible for safeguarding your own money, valuables, and property. 5. Obey the requests made by adult staff and individuals who have been given authority by the Pastor, i.e., a rafting guide. 6. Be extremely alert when encountering people you do not know. Be polite and kind, but do not trust anyone unless staff members have acknowledged their authority and trustworthiness. 7. Wear clothing that is appropriate to the SSM Code: You may not wear clothing that displays questionable material slogans, advertising, or groups that promote questionable behavior. T-shirts with sleeves need to be worn by both young women and young men. No tank tops or muscle shirts. Pajamas, pajama bottoms, and other sleepwear may not be worn at a SSM function except to sleep in. MEN: You must wear appropriate swimwear (no speedos) that fit and do not show your underwear. You may not engage in visible sagging and a shirt must either be tucked-in or cover the top of the pants and shorts you may wear. WOMEN: You may not wear tank-tops, mid-riff tops, spaghetti strap tops, two-piece bathing suits or revealing one piece bathing suits (no holes, mesh, etc), tight/revealing tops, yoga pants/tights, short shorts, or low-cut jeans. DISCLAIMER: Clothing appropriateness is subject to the judgment of the Student Ministries Staff. The staff reserves the right to make that judgment based upon Student Ministry standards and will not consult individual family standards. Students will be asked to change attire if it is determined that clothing is not appropriate according to the staff s judgment. Please be conservative and wise in your judgment when you pack for a Stonebriar Student Ministry event. 8. When designated, males may not be found in female-exclusive areas, and females may not be found in male-exclusive areas. 9. Do not engage in public or private displays of affection and romantic drama. 10. Raiding, practical joking, and pranks are prohibited. 11. Electronics use may be limited by staff at Student Ministry events. Please do not bring ANY personal entertainment devices for the weekend (ipods, ipads, cell phones, gameboys). 12. Contact a staff member if you do not feel well or suffer an injury. 13. Do not wander away from the group or across defined boundaries without alerting a staff member. Never walk around alone or be alone at anytime. 14. Do not approach stray animals or wildlife if encountered. 15. Escape thunderstorms by quickly moving into the closest building. 16. Drugs and alcohol are prohibited. Tobacco products are prohibited at Student Ministry events and functions. 17. Do not bring hazardous or inappropriate equipment or materials, which include weapons, laser pointers, matches and lighters, and fireworks. The staff reserves the right to make their own judgments on what is hazardous and inappropriate. 18. Do not pack, self administer or distribute medications of any kind to yourself or others. This includes home remedies, essential oils and any over the counter non-prescription medication. All medication must be turned in to the staff at check in for the event. All over the counter and prescription medications are to be given to staff members to be distributed on extended trips. Do not pack, purchase, ingest or distribute any types or forms of medication on your own. Pine Cove Fall Retreat 2016 Event Specific Rules: 18. Follow the event schedule, be on-time to each activity, and be engaged in each activity throughout the weekend. You may not choose to hangout at different locations and not participate in the conference. 19. DO NOT BRING cell phones. Staff phones are available for use to contact home. 20. DO NOT BRING, PURCHASE or CONSUME energy drinks of any kind (Gatorade is an exception) during a student ministries event. By signing below, I agree to follow the rules as they are outlined above. I understand that if I break the rules, the Student Ministries Staff will take disciplinary action. Disciplinary action may include being asked to correct a behavior, restriction from activities, staying with a staff member, restitution for broken items, confiscation of property, a call home to your parents, or in cases of gross misconduct, being sent home. Student Signature: Date: By signing below, I have read the rules that my son or daughter will be under at camp. In very serious disciplinary matters (gross misconduct or the possession and/or use of drugs), I may be asked to make arrangements and pay to have my son or daughter sent home. Parent Signature: Date: It is your responsibility to abide by the code while you are a part of Stonebriar Student Ministries events. KNOW THE CODE! Stonebriar Community Church Student Ministries Junior High High School

7 EXHIBIT A MINISTRY EVENT OF STONEBRIAR COMMUNITY CHURCH NAME OF PARTICIPANT: DATE OF EVENT: October 14 th 16 th, 2016 TYPE OF EVENT: JUNIOR HIGH MINISTRY PINE COVE FALL RETREAT 2016 VENUE NAME: VENUE ADDRESS: Pine Cove Ranch & Timbers Camps Pine Cove Ranch Camp Pop McKenzie Rd Flint, TX List ALL planned activities for this event and the associated risk(s) for each activity: ACTIVITY ASSOCIATED RISK(S) 1. Bus & Car Travel 1. Accidental Injury, death and/or dismemberment, car wreck, external injuries, illness due to travel, emotional trauma, etc. 1. Cabin Camping at Pine Cove Ranch/Timbers 2. Accidental injury, death and/or dismemberment, external injuries, internal injuries, allergic reactions, falling, accidental exposure to toxins and/or poisons, exposure to and/or contamination of infections/diseases, emotional trauma, burns, choking, exposure to offensive people or scenery; animal attack, insect/tick/bug invasion, falling, building structural collapse, fire, etc. 2. Recreational Free Time Activities & Pine Cove Activities/Games such as but not limited to Sports, Dodge ball, Frisbee Golf, Football, GaGa Ball, Pickle Ball, Barn Swing, Swimming, Messy Games, Large group camp games, On Stage Games, etc. 3. Accidental injury, death and/or dismemberment, vehicular accident, external injuries, exposure to offensive people/scenery, falling, heat exposure/exhaustion/stroke, hypothermia, animal attacks, fire, exposure to and/or contamination of infections/diseases, rashes, insect/tick/bug invasion, equipment malfunctioning/failure, emotional trauma, etc. JHM Pine Cove Fall Retreat 2016, Exhibit A, Page 7 of 2

8 3. Adventure Activities such as but not limited to Zip Line, Horseback Riding, Skate Park, Canoes/water activities, barn swing, hiking, etc. 4. Accidental injury, death and/or dismemberment, external injuries, internal injuries, dehydration, heat exposure/exhaustion/stroke, allergic reaction, falling, accidental exposure to toxins and/or poisons, exposure to and/or contamination of infections/diseases, emotional trauma, inclement weather, animal attacks, exposure to and/or contamination of infections/diseases, rashes, equipment malfunctioning/failure, emotional trauma, etc. 4. Food Consumption and Handling - Cafeteria/Family Style Meals and General Store/Snack shack, etc 5. Accidental injury, death, food poisoning and/or dismemberment, external injuries, allergic reactions, falling, accidental exposure to toxins, and/or poisons, exposure to and/or contamination of infections/diseases, unintentional contact with offensive people/situations, emotional trauma, inclement weather, etc. I, the undersigned, agree and understand that the ASSUMPTION OF RISK, VOLUNTERY RELEASE, AND INDEMNITY AGREEMENT (the Agreement ) that was signed by or for Participant and provided to and for the benefit of the Church fully applies, is incorporated herein by this reference, and is enforceable in regard to the above-referenced Event and all risks associated therewith. Without limiting the Agreement in any way, I, on behalf of myself and Participant, and our respective personal representatives, assignees, insurers, heirs, executors, administrators, spouse and next of kin, hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Stonebriar Community Church and its directors, officers, employees, agents, volunteers, as well as its/their successors, assigns, affiliates, subordinates, and subsidiaries (collectively referred to as the Church ), and RELEASE, WAIVE AND DISCHARGE the Church from any and all liability for any and all loss, damage, injury, death, and expense to me or the Participant or his/her/our property, whether caused by negligence or otherwise (except not for any gross negligence or willful misconduct on the part of the Church) while I am, or the Participant is, participating in a Ministry Event and any other activities in connection therewith or described herein. PRINTED name of Legal Guardian (if Participant is under 18 years of age) SIGNATURE of Legal Guardian (if Participant is under 18 years of age) Date Signed Exhibit A Revised RG / RAF

9 JHM Pine Cove Fall Retreat 2016, Exhibit A, Page 9 of 2