ECOBYOUTH Universal Waiver Form 2024-2025 • Ephrata Church of the Brethren

Valid from September 2024 - August 2025

Youth Information (5th-12th Grade)

Please fill out the following information as it pertains to your youth.

First Name *

Last Name *

Preferred Name *

School Grade *

Date of Birth *

Gender *

School *

Mailing Address *

Youth Email Address *

Youth Home Phone # *

Youth Cell Phone # *

If other, what other social media does your youth use? *

Contact Consent

Are you okay with one of our approved adults (definition in ECOB Safe Church Child Protection Policy, available upon request) contacting your youth directly using one of these methods?

Via cell phone? *

Via social media? *

Parent/Guardian Information

This is the space for information pertaining to YOU, the Parent or Guardian.

Full Name(s) *

Email Address(es) *

Please list all phone numbers where the parent/guardian can be reached (type: home, cell, work, etc.)

Name - Number - Type

Example:

Chris - (717)715-6861 - cell

Chelsea - (717)368-2173 - cell

Chris - (717)733-1229 - work

Phone Number(s) *

Emergency Contacts

Please list those who we can count on in an emergency situation (can be parent/guardian). Please list at least two people. (If these were to ever change, please contact Chris, chris@ecob.church, so we can have the most updated contact info.)

Full Name - Number - Relationship to Youth

Example:

Chris Reinford - (717)715-6861 - Father

Emergency Contact Information *

Parental/Guardian Consent

The undersigned does hereby give permission for my child ____________________________ (childs name) (Participant), to attend and participate in any Ephrata Church of the Brethren (ECOB) children/youth ministry activities, events, retreats and childcare during the period of September 1, 2024 August 31, 2025.

LIABILITY RELEASE: In consideration of ECOB allowing the Participant to participate in children/youth ministry (Sunday worship, Sunday meeting, Activities, Events, Retreats, Lock-Ins, Trips) and childcare, I, the undersigned, do hereby release, forever discharge and agree to hold harmless ECOB, its pastors, directors, employees, volunteers and teachers (collectively herein the Church) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities and childcare. I the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in children/youth ministry activities and child care, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

EARLY RETURN HOME POLICY: Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by ECOB. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

I have read and understand the above statement. *

Yes

Youth Participant Signature *

Parent/Guardian Signature *

Date *

Medical Insurance Information

Are these person/persons covered by a medical insurance policy? *

Yes

Name of Policy Holder and Relationship to child *

Insurance Company, Policy #, and Group ID # *

Type of Medical Plan *

Group

Individual

Family

Primary Care Physician

Primary Care Physician's Name *

Primary Care Physician's Phone # *

Name of Practice *

Date of last Tetanus Shot *

Dentist's Name and Phone number

Medication

List all medications the youth will take during any youth ministry trips, retreats, or events. This includes any prescription, non-prescription medications, herbal supplements and vitamins. Any participant under the age of 18 is required to give ALL MEDICATIONS to the adult youth leader in their original containers with complete dispensing instructions before the start of the event. Youth are not permitted to carry any prescription or non-prescription medication and will be sent home at the parent/guardian’s expense if they do.

Medication Name: Dose; Treatment for; Dispensing instructions

Ex: Zyrtec: 5mg; Seasonal Allergies; Take one pill daily in the morning with food

Medication Information *

Over-the-Counter Medication Permission

Do you give permission for your child/youth to be given over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth ministry event?

Options *

No. Contact me or get medical help if my child has any minor medical problem.

Yes. I give permission for an adult youth leader to give my child approved over-the-counter medications as directed on an as needed basis to treat non-emergency medical conditions.

Parent/Guardian Signature *

Medical Conditions

Please answer in detail if applicable or write N/A. Attach additional pages if necessary.

List any medical conditions you have (asthma, diabetes, epilepsy, etc.):

List any allergies (drug/medicine, food, and/or environmental) and the severity and type of reaction:

Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know.

ECOBYOUTH Ministry Covenant of Community Expectations

The following rules and guidelines are equally binding on adult leaders/chaperones and youth.

Non-Negotiable Rules

Any participant failing to abide by these rules will be sent home immediately at personal/family expense.

• No use of tobacco, illicit drugs, or alcohol to, from, or during any event/trip.

• Presence at and full participation in all group activities, including adherence to curfews and other time-related instructions; will not leave event site unless given proper permission.

• No sexual misconduct (defined as exposure, touching, or inappropriate reference to body areas normally covered by undergarments); this includes no public displays of affection (PDA).

• Must be in assigned rooms by designated time, coed visitation only in communal spaces.

• Treat everyone with respect, do not harm anyone or anything emotionally or physically.

• Will not bring weapons, offensive material, pornographic images, or anything that is explicit.

• Will not break any American laws in the United States or any other country.

Guidelines for Living in Christian Community

• Adults and youth will be equally responsible for performing assigned tasks in a timely and cooperative manner.

• Participants will be respectful, encouraging, and will maintain a positive attitude toward others at all times, recognizing Christ’s presence in each other.

• Participants will be respectful of both common living spaces and the property of others.

• Participants will avoid the use of foul language, cursing, or any speech (including “humor”) which puts down, makes fun of, or stereotypes other persons or groups.

• Sleeping areas for males and females will be separate.

Youth Participant’s (or Adult Leader’s) Statement: By signing this form, I pledge to honor God and respect others during these activities by following the rules and guidelines printed above. I understand that I cannot participate in the activity unless this completed form is on file.

Youth Participant's or Adult Leader's Signature *

Date *

Parent/Guardian’s Statement: By signing this form, I agree to support the Covenant of Community Expectations printed above and will accept responsibility for the payment of my child’s return transportation should they break one of the non-negotiable rules.

Parent/Guardian Signature *

Date

Photography/Video Release

I agree that ECOB may photograph and record my child/dependent’s likeness and activities (Images)[1] during church-related activities. I grant the following rights to ECOB: permission to use and re-use, publish and re-publish, and modify or alter the Image(s) taken during the shoot. Use of the Images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the church website and on the Internet, and worldwide in perpetuity for the purposes stated above.

I waive my right to inspect or approve any editorial text or copy that is used in connection with the Images and release and discharge ECOB from any and all claims arising out of use of the Images for the purposes described above, including any claims for libel, invasion of privacy, or other tortuous act.

I have read the foregoing. I fully understand its contents, understand that this agreement does not expire, and confirm my agreement by signing below. I am over the age of 21 and have legal capacity to sign the release.

[1] Image means all photographs, film, or other recordings taken of you as part of the Shoot.

I have read and understand the above information: *

I agree to this statement and give permission to ECOB.

Parent/Guardian Signature *

Date *

NEW: ECOBYOUTH Overnight Event Policy

Any youth that is not a member of ECOB, or a regular attender of Worship @ ECOB, will need to attend at least 2 Sunday Night Youth Group nights occurring before the overnight event (Engage or Elevate) in order to attend.

NEW: ECOBYOUTH Sunday Night Youth Covenant

Upon check-in at each Sunday Night Youth Group, all youth will be required to agree to this covenant. Violation of this covenant could require disciplinary action, and possibly being sent home early. Event volunteers and youth leaders from ECOB reserve the right to call the parent/guardian of any youth who breaks this covenant.

As a representative of the Youth of Ephrata Church of the Brethren, I agree that I am responsible for my actions. I understand that I am a guest of all the places I enter (ex. The Church, Restaurants, Event facilities, etc.) and I will be on my best behavior at all times.

Non-Negotiable Rules: Any participant failing to abide by these rules will be sent home immediately at personal/family expense.

• No use of tobacco, illicit drugs, or alcohol.

• Presence at and full participation in all group activities and will not leave event site unless given proper permission.

• No sexual misconduct (defined as exposure, touching, or inappropriate reference to body areas normally covered by undergarments); this includes no public displays of affection (PDA).

• Will not bring weapons, offensive material, pornographic images, or anything that is explicit.

Guidelines for Living in Christian Community

• Participants will be respectful, encouraging, and will maintain a positive attitude toward others at all times, recognizing Christ’s presence in each other.

• Participants will be respectful of others emotionally and physically,

• Participants will respect the property of others.

• Participants will avoid the use of foul language, cursing, or any speech (including “humor”) which puts down, makes fun of, or stereotypes other persons or groups.

NEW Phone Policy: This experience has been designed to allow me time to bond with the group and give me the opportunity to mature in my faith. With this in mind, I will allow ECOBYOUTH Volunteers to put my phone in a designated location to be kept safe: For Engage this will be from 5:00-6:00pm, and for Elevate this will be from 6:30-8:00pm. Phones are allowed during free time, 6:00-6:30pm, and after 8:00pm for Elevate.

By signing this covenant, I agree to abide by the rules set out for me.

Consequences of Not Following the ECOBYOUTH Sunday Night Youth Covenant

If this covenant is broken the following will take place.

On the night of the offense, the youth involved will be sent home immediately.
1st Offense: The youth will not be allowed to attend Sunday Night Youth Group (Engage or Elevate) for one week following the offense.
2nd Offense: The youth will not be allowed to attend Sunday Night Youth Group (Engage or Elevate) for one month following the offense.
3rd Offense: The youth will not be allowed to attend+ Sunday Night Youth Group (Engage or Elevate) and ECOBYOUTH events for the remainder of the year (until Aug. 2025)
At each step, ECOB’s Director of Youth & Young Adults will create incident reports and talk to parents of the youth involved the week immediately following the incident.
Support and mentorship are available from the ECOB Staff and ECOBYOUTH Volunteers if requested by the parents/guardians and/or youth.

As a Parent/Guardian of the above-named youth, I agree to having my youth follow the Overnight Event Policy and Sunday Night Youth Covenant.

Parent/Guardian Signature *

Date *