EDSD: Youth Waiver for Night Watch

Participant Name *

Participant Email *

Birth Date *

Grade (open to 7th through 9th) *

Signature of Parent or Legal Guardian *

Name of Parent of Guardian *

Date *

Emergency Contact Information

Parent/Guardian(s) Name(s) *

Street Address *

City *

State *

Zip Code *

Email Address *

Additional Email Address

Phone Number *

Phone Type *

Home, Mobile, etc.

Additional Phone Number

Phone Type

Home, Mobile, etc.

Other Emergency Contact Name

Relationship to Participant

Phone Number

Phone Type

Home, Mobile, etc.

Other Emergency Contact Name

Relationship to Participant

Phone Number

Phone Type

Home, Mobile, etc.

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Health Care Information

Physician Name *

Phone Number *

Medical Insurance Company *

Policy/Group Number *

Name of Policy Holder *

Please list any allergies to drugs, foods, plants etc.:

Please list any prescription medication to be taken by the participant (including what it is taken for, when it is to be taken, dosage information, and any special procedures):

Please list any non-prescription (over-the-counter) medication you do NOT want dispensed to your child:

Please list any additional information relevant to participating in Youth Group activities (dietary needs; surgeries or serious injuries; chronic or recurring illness; medical conditions such as epilepsy or diabetes; psychiatric counseling or indications, etc.):

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You have received this parental consent form to both inform you and to request your permission for your child’s photo/image and name to be published mockup.edsd.org and/or any other websites maintained, owned, and/or administrated the Episcopal Diocese of San Diego. The law requires that we ask for your permission to use information about your child. Pursuant to law, we will not release any personally identifiable information without prior written consent from you as parent or guardian. Personally identifiable information includes youth names, age, grade, and photo or image. If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time in writing by sending a letter to the Youth Collaborative Missioner, Charlette Preslar, and such rescission will take effect upon receipt.

Check one of the following choices:

I/We GRANT permission for this youth’s photo/image and all other personal identifiers listed above to be published on the Episcopal Diocese of San Diego public website or any site operated by the Episcopal Diocese of San Diego

I/We GRANT permission for ONLY a photo/image that includes this youth without any other personal identifiers to be published on the Episcopal Diocese of San Diego public website or any site operated by the Episcopal Diocese of San Diego.

I/We DO NOT GRANT permission for photo/image that includes this youth to be published the Episcopal Diocese of San Diego public website or any site operated by the Episcopal Diocese of San Diego.