Microsoft word - general permission slip 2013-2014.docx
GENERAL PERMISSION SLIP FOR SCHOOL YEAR 2013-2014
Name: ____________________________________________ Birth Date: ________ / ____ / ______
Grade (2013-2014 school year): _______________
Home Address: ________________________________________________ Zip: _____________
Father’s Name: ___________________________________
Mother’s Name: ___________________________________
If parents cannot be reached in an emergency, please contact:
Name: ________________________________________________
Home Phone: (____) ____________ Work Phone: (____) ____________ Cell Phone: (____) ___________
(In the event of an emergency, every effort will be made to contact the parent(s)/guardian or designated person)
Family Physician: __________________________________________________ Phone: (____) _____________
Insurance Carrier/Plan Name: _________________________________________________________________
Please list any Allergies: ______________________________________________________________________
Is the participant under the care of a Physician: Yes No Taking any medications: Yes No
If yes, please explain: __________________________________________________________________
Please circle any medications that can be given to the participant:
Other appropriate over-the-counter medicines: _______________________________________________________
We, the undersigned parent(s) or legal guardian(s) of ______________________________ a minor, has my permission to attend youth events. We hereby authorize youth leaders of FUMC, as agent(s) for the undersigned, to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital case which is deemed advisable by, and rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s), especially in case of emergency, to give specific consent to any such diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his or her judgment may deem advisable. I understand that all reasonable safety precautions will be taken by the leaders of this activity, and that the possibility of an unforeseen hazard does exist. I further agree not to hold First United Methodist Church, Bakersfield, its DIRECTORS, EMPLOYEES, OR AGENTS (Herein referred to as “church”) liable for damages, losses, diseases, or injuries incurred by the minor(s) listed on this form TRANSPORTATION CONSENT STATEMENT We, the undersigned parent(s) or legal guardian(s) of ______________________________ a minor, give permission to the church to transport said minor in a vehicle (with either 1 or 2 adults in vehicle) to scheduled youth events and at scheduled youth events.
Information is confidential and will be made available only to the health supervisor and those people who
are directly responsible for your child’s care. For their safety and well-being, no participant will be
allowed to attend a youth event without a completed and signed Medical Authorization & History form.
By checking this box you give First United Methodist Church permissions to use photos of your youth taken during
events, programs and trip on our website and print publications. CODE OF CONDUCT COVENANT During the meetings and events under the sponsorship and guidance of First United Methodist Church, I recognize that I am a representative of the Christian Community and I am responsible for my actions. I understand that by signing this Covenant, I agree to abide by the following guidelines: I Shall: 1. Embrace inclusiveness by making sure that everyone feels welcome and important. 2. Respect the physical and emotional well-being of others by “doing unto them as I would have them do unto me.” 3. Respect the health of my own body by refraining from the use of tobacco, alcohol, and illegal drugs. I understand that
the use of these substances is absolutely prohibited and illegal.
4. Respect the things I use and the property of places I visit. The areas used for all events, including transportation, shall
5. Participate fully in ALL scheduled group activities and abide by additional group guidelines. 6. Act appropriately with members of the opposite sex. This means no couples alone at any time, and no public displays
7. Follow all instructions given by group leaders and chaperones without protest. (This does not mean an instruction may
not be politely and discretely questioned if it seems unreasonable).
8. Stay within the group or assigned sub-group at all times. I will not wander off alone or leave the activity site unless
granted permission by an adult, and I will report for all designated check-in times.
9. Hold safety in the highest regard and refrain from compromising my own safety or another’s safety. 10. Provide a trusting environment for my peers. When others share something about themselves in a group discussion, I
will not repeat that information to other friends outside of the group.
GUIDELINES FOR CONSEQUENCES Consequences will focus on restoring peace with reconciliation among the parties involved. The goal of resolving each problem will be growth and learning through repentance and forgiveness. Any problems encountered will be handled within the group and by the adult leaders to the extent that this is possible. However, should a situation persist or become uncontrollable, the parent/guardian will be contacted and informed of the problem. Should the situation be urgent, the parent/guardian will be contacted immediately and will be responsible for picking up the youth from an event or providing for his/her transportation home. Child/Youth and Parent/Guardian Signature: In signing this form and covenant, I vow that I have read and understand these guidelines. I recognize that a covenant is a binding promise, and my signature is testimony that I agree to adhere to the provisions of this covenant. Signature of Child/Youth ____________________________________Date _____________ Signature of Parent/Guardian_________________________________Date _____________
Information is confidential and will be made available only to the health supervisor and those people who
are directly responsible for your child’s care. For their safety and well-being, no participant will be
allowed to attend a youth event without a completed and signed Medical Authorization & History form.
COLORADO REPRODUCTIVE ENDOCRINOLOGY 4600 HALE PARKWAY, SUITE 350 PATIENT NAME: DENVER, CO 80220 303-321-7115 FAX 303-321-9519 ATIENT HISTORY FORM PHYSICIAN: Please answer the fol owing questions to the best of your ability. The information obtained wil enable us to provide you with optimal medical care. If you do not know the answer to any questions, you may leave it
PLAN FORMATIVO PRÁCTICUM – TRABAJO ACADÉMICO DIRIGIDO Título Proyecto: Papel del óxido nítrico en la biología celular del liquen y en su sensibilidad a la contaminación atmosférica Grupo de trabajo: Ecotoxicología y Salud Ambiental (grupo interfacultativo Dirección del TAD: Prof. Myriam Catalá Alumno: de CC. Ambientales con sólida formación en bioquímica, botánica, microbi