Archwinnipeg.ca

Combined Consent and Health Form - 2013
Your signature at the end indicates your consent and acceptance of the provisions included in
this document.
Name _____________________________________________________________________________
Parish/School _____________________________________City & Province___________________
Age _____________ Gender ________ Home Phone ( ) _____________________________
Mailing Address ____________________________________________________________________
City, Prov & Postal Code_____________________________________________________________
Emergency Contact:
Name: ____________________________________ Phone Number: ___________________________
Relationship_______________________________
Name: ____________________________________ Phone Number____________________________
Relationship_______________________________

PARTICIPATION CONSENT : I, (Name of Parent or Guardian) __________________________
grant permission for my son/daughter to participate in the YouthLeader program.
LIABILITY WAIVER: I will not hold the Roman Catholic Archiepiscopal Corporation of
Winnipeg, the Roman Catholic Archdiocese of Winnipeg, its parishes and schools, the Center
for Ministry Development, YouthLeader program administrators and facilitators, parish team
leaders, or the program facility responsible in the event of any injury or accident to my son or
daughter while participating in the YouthLeader program and/or traveling to and from the
program.
STATEMENT OF HEALTH: I hereby warrant that, to the best of my knowledge, my child is in
good health and able to participate in all program activities. (Please submit a statement
indicating limitations and/or conditions of which we should be aware.)

INSURANCE INFORMATION
Health Insurance Co.: __________________________ Policy No. ___________________________
FAMILY PHYSICIAN INFORMATION
Physician or Clinic: ________________________________________Phone ____________________
Physician/Clinic Address_____________________________________________________________
ALLERGIES/DIETARY NEEDS: Please attach a statement noting all known allergies, including
how the child has been treated and with what medication. If medications are needed
occasionally or regularly, please send them with your child in case of need. If your child has
special dietary needs or restrictions, please attach a statement listing these dietary concerns.
MEDICATIONS: Any medications brought to the program should be clearly labelled and in
their original container. Please list any prescription or approved non-prescription drugs your
child is presently taking. Include product name and physician's instructions on dosage and
frequency.
____________________________________________________________________________________
____________________________________________________________________________________

I understand that all prescription medication will remain in the possession of the adult team
leader and be dispensed as prescribed. I grant permission for non-prescription medication
(such as ibuprofen, Tylenol, throat lozenges, cough syrup) to be given to my child, if deemed
advisable. If there are any non-prescription drugs you do not want administered to your
child please list them below:
_______________________________________________________________________
____________________________________________________________________________________

OPERATIONS OR SERIOUS INJURIES: (Within the past 18 months)
Operation/Injury ___________________________________________Date ____________________

COMMUNICABLE DISEASES: Please notify your YouthLeader Sponsor immediately if your
child has been exposed to any communicable disease (mumps, measles, chicken pox, etc.)
within three weeks prior to attending the YouthLeader program.

MEDICAL EMERGENCY: In case of medical emergency, I understand that a reasonable effort
will be made to contact parents or guardian of participants. In the event that I cannot be
reached, I hereby give permission to the physician selected by the Team Leader from the
parish/school to hospitalize, secure proper treatment for, and to order injection, anesthesia, or
surgery for my child, as named herein.

SIGNATURE OF PARENT OR GUARDIAN: I certify that the above information is correct and
give permission for my child to be transported in privately owned vehicles and/or via public
transportation for approved YouthLeader program activities; and for the release of medical
records to an attending physician in case of illness.
I fully understand the consequences of the foregoing statements and sign this form knowingly,
freely, and willingly. (Your signature must appear below or your child will not be permitted to
participate in the YouthLeader program.)
Signature _________________________________________________Date ____________________

USE OF PHOTOS: I hereby grant Roman Catholic Archiepiscopal Corporation of Winnipeg,
the Roman Catholic Archdiocese of Winnipeg, its parishes and schools and the Center for
Ministry Development permission to use photos or videos of my child taken during program
activities, or quotations from my child for future program promotion purposes.
Signature_____________________________________________ Date__________________
Code of Behaviour 2013

We are happy and excited that you are joining us as part of YouthLeader 2013. The Code of
Behaviour has been developed as a way of helping participants understand what is expected of
them during the week, and of making the learning experience a healthy and growthful one for
all involved. Please read through the Code carefully, as you will be expected to honour and
uphold it throughout your time with us.
 As necessary as rules are to maintain order, they can't and won't guarantee a successful YouthLeader experience. Success depends on people's willingness to work together for the common good.  Participants take part in YouthLeader as part of a parish or school team. The adult leader of each team maintains primary responsibility for the actions of his or her team members. The sponsoring parish or school and the families of team members assume responsibility for any damage done to the facilities.  Participants are expected to attend all sessions unless explicitly excused by the Program  Name badges should be worn during all program activities.  Dress throughout the YouthLeader experience is casual, however shirts and shoes must  Socializing should take place only in the designated public areas of the housing facility. No visiting is allowed in sleeping areas occupied by the opposite sex.  Each day will be a busy one - making adequate sleep a necessity. Participants must be in their respective rooms by curfew time. The noise level in the sleeping areas should be kept at a minimum. Scheduled quiet and silent times must be honoured. Only the Program Director can alter curfew times or the timing of any other scheduled activity.  Smoking is not allowed during scheduled group activities or in the facility. All other smoking restrictions must be honoured (ages, locations, times, etc.)  The purchase, possession or consumption of alcohol or drugs by participants will result in immediate dismissal from the program. Major infractions of the Code of Behaviour will meet with the same consequences.
Parent or Guardian (if participant is not 18 years of age): I agree that my child shall abide by
the rules and regulations outlined in the YouthLeader Code of Behaviour. I have reviewed it and
discussed the Code with my child prior to signing this form. I agree that if my child fails to
consistently abide by the Code or engages in a serious infraction of the Code, he or she may be
immediately dismissed from the YouthLeader program and sent home at my expense.
Signature __________________________________________ Date ___________________

Youth Participant: I understand and agree to the YouthLeader Code of Behaviour.
I also understand that my parent(s) or guardian will be notified at the time of any infractions
requiring my dismissal from the program and that I will be sent home at my own or their
expense. (Your signature must appear below in order to participate in the YouthLeader
program.)
Signature _________________________________________ Date ____________________

Source: http://www.archwinnipeg.ca/docs/Consent%20form.pdf