CCYM Medical Liability and Conduct Agreement 2025

Covers all CCYM activities and events from January 1, 2025 - December 31, 2025

Personal Information

Student First Name

Student Last Name

Birthdate

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email to use for event communication

Medical Information

Emergency Contact

Emergency Contact's Phone Number

Doctor

Doctor's Phone Number

If you checked anything above, please provide additional details

Date of Last Tetanus Shot

Epi Pen needed?

Yes

No

Activity Restrictions

Medications

You are required to list any over-the-counter (OTC) and prescription medications you are bringing with you. Student agrees they will not share OTC or prescription medications.

I am NOT bringing any OTC or prescription medications with me to these activities/retreats

I am bringing the following OTC or prescription medications with me to these activities/retreats

OTC Medications:

Prescription Medications:

Insurance Information

Our church’s insurance serves as secondary coverage. If your child has medical insurance, your provider will be billed for any medical expenses incurred due to illness or injury during a CCYM activity or event.

Insurance Company Name

Insurance Phone Number

Insurance Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Policy Number

Primary Card Holder

Christ Covenant Church carefully plans and supervises all activities. However, despite these precautions, unforeseen events may occur. By signing this form, parents or guardians acknowledge and accept all risks associated with CCYM events/activities in 2025. They agree not to hold the church or its staff liable for any damages, injuries, or losses to persons or property. This agreement applies to the minor listed on this form, and the signature serves as both a medical and liability release.

In case of an emergency during any CCYM event/activity in 2025, if the parent or guardian cannot be reached, they grant permission for a physician or dentist selected by CCYM staff to provide necessary treatment, including hospitalization, injections, anesthesia, or surgery, as needed.

Media Release

Additionally, by signing below, the parent or guardian grants permission for CCYM staff or their designees to use photos or videos of the student participating in events or activities for communication purposes related to Christ Covenant Church.

Student Name Printed

Parent/Guardian Name Printed

Parent or Guardian Signature

Date Signed

Medication Administration Release

This section only to be completed if your student needs assistance taking their OTC or prescription medications

Medications need to be in original bottles with the student's name on all medications and put into a clear bag, also with the student's name.

By signing below, I authorize the CCYM Staff or designated volunteer to administer the following medications to my student during all relevant CCYM activities or events in 2025. On behalf of my student, I absolve, release, and indemnify Christ Covenant Church, its staff, and its volunteers, from any and all liability whatsoever that may result from my student taking or not taking this medication.

Parent or Guardian Signature

Date Signed

Conduct Agreement

Student Agreement

Be respectful
Participate fully
Obey policies and procedures outlined by CCYM staff and volunteers
No cussing or gossiping
Keep yourself and others safe
No engaging in any illegal activities such as:
- Possession or consumption of alcohol, tobacco, or illegal drugs
- Possession or use of firearms or weapons
- Any form of inappropriate sexual conduct
- Any form of physical, psychological, or emotional abuse

Violation of Student Agreement
The student agrees to adhere to the commitments outlined above. If the student fails to comply with these commitments, they will first receive a verbal warning. If the issue persists, the student will meet with a CCYM staff member to discuss the violation. Should further action be needed, the parents will be notified, and the staff member will collaborate with the parents to determine the appropriate course of action. Additionally, if the student violates any of the conduct guidelines, they may be sent home at the parent or guardian's expense.

Student agrees by signing that they understand and will comply with the conditions of the CCYM Conduct Agreement

Parent agrees by signing that they understand and agree to comply with the conditions of the CCYM Conduct Agreement