(cache) General Convention Youth Program 2009

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General Convention Youth Program 2009

The General Convention 2009 Youth Program, July 9-12, 2009 is open to all students in grades

7-12 and accompanying sponsors. The program will include:

•

Educational program designed to introduce students to the work of the General

Convention and provide a basic overview of the Episcopal Church. This element of

the program will include a dialogue with one or more of the visiting Anglican

Primates from outside of the United States.

•

Access to the General Convention including the exhibit hall and the fabulous

Sunday Morning Celebration of the Eucharist.

•

Participation in Habitat for Humanity construction projects in Southern California…

and one home that will be under construction at the Anaheim Convention Center!

Youth Program participants will have the opportunity to hear about the work of

Habitat from Jonathan Reckford, CEO of Habitat for Humanity International

•

Evening celebrations and fun times on the campus of UC Irvine. These

evenings will include great music, inspiring worship, and activities designed to make

new friends from around the Episcopal world.

•

Admission to Episcopal Youth Night at DISNEYLAND!

Two options for participation are available:

•

Full participation in the General Convention Youth Program (see above)

including 4 nights and 10 meals on the campus of UC Irvine.

Transportation to and from UC Irvine, Habitat project sites, and the Anaheim

Convention Center is included.

Registration: $525.00 (if registered by May 30, 2009. $575.00 after May

30, 2009)

•

Full participation in the General Convention Youth Program (see above)

including 3 lunches. Lodging and other meals arranged on your own.

Transportation to and from Habitat project sites, and activities held at UC

Irvine included.

Registration: $195.00 (if registered by May 30, 2009. $245.00 after May

30, 2009)

Questions can be directed to:

The Rev. Michael Archer, General Convention Youth Program Coordinator

Phone: (714) 962-7512

Email: michaeld1104@sbcglobal.net

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General Convention Youth Program 2009

We are happy to work with you, your family, and your youth group during the upcoming

General Convention in Anaheim. The General Convention Youth Program is open to

students in grades 7-12. The Habitat for Humanity elements of the program will differ

slightly for students under the age of 16, but all students will have the opportunity to

participate in this exciting mission project.

In order to better serve you we ask that you complete the checklist below of the forms

needed for the Youth Program. Please make sure they are filled out completely and then

sent to:

The Episcopal Diocese of L.A.

840 Echo Park

Los Angeles, CA 90026

Attention: General Convention Youth Program

A ratio of 1 adult for every 8 students is required. If you are an adult sponsor

accompanying students to the General Convention Youth Program, please contact the

General Convention Youth Coordinator directly for registration information.

Please direct inquiries to:

The Rev. Michael Archer, General Convention Youth Coordinator

Phone: (714) 962-7512

Email: michaeld1104@sbcglobal.net

Checks should be made out to: Episcopal Diocese of Los Angeles. On the memo line,

please write: GC Convention Program – Youth

Youth Program Registration Form

Media Release form

Parental Affirmation

Waiver and Release

Medical Consent

Medication Form

Field Trip Form

Electronic Device Release

Health History

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YOUTH PROGRAM ENROLLMENT FORM

Full Name of Youth:_______________________________________________________

Age:______ Grade in Fall:______ Birthdate:____/____/____

Home Address:

_________________________________________________________________

Street

_________________________________________________________________

City/State/Zip

Email:____________________________________________________________

Home Phone: __________________________ Cell Phone:______________________

Sponsoring Church and Location:____________________________________________

Address while at convention (check one):

______UC Irvine

______Other

If other, please provide the following:

Name of location:___________________________________________________

_________________________________________________________________

Street

_________________________________________________________________

City/State/Zip

Phone Number while at convention:___________________________________________

Adult Responsible for Student at General Convention:

Name: _____________________

Relation to student:____________________

Address: __________________________________________________________

Street

____________________________________________________________

City/State/Zip

Phone: Home:_______________________ Cell:__________________________

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Emergency Contact(s):

Name:______________________ Relation to student:____________________

Phone: Home_____________________ Cell:____________________________

Name:______________________ Relation to student:____________________

Phone: Home ____________________ Cell:___________________________

Parent(s) Name:__________________________________________________________

Phone:__________________________________________________________________

Email address____________________________________________________________

Dietary needs____________________________________________________________

Allergies:________________________________________________________________

Other special needs*_______________________________________________________

________________________________________________________________________

*Examples: Hearing Impaired; Physical Disabilities; ESL; Learning Disabilities; etc.

Please check one:

_____ I am registering for the full program with room and board at UC Irvine:

$525.00 (before May 30, 2009)

$575.00 (after May 30, 2009)

______I am registering for the full program without room and board:

$195.00 (before May 30, 2009)

$245.00 (after May 30, 2009)

(25% registration deposit required _______________) non refundable

Amount enclosed______________

Make checks payable to Episcopal Diocese of Los Angeles

Balance will be due by June 15, 2009

Registrations, Deposit and Balance should be mailed to:

Diocese of Los Angeles: General Convention Youth Program

840 Echo Park Ave Los Angeles, CA 90026

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MEDIA RELEASE FORM

On behalf of _________________________, (the “Minor Child”), the undersigned parent

does agree to grant to the Domestic and Foreign Missionary Society ("The Society") and

the Episcopal Diocese of Los Angeles (the “Diocese”), permission to record on film,

video tape, or audio tape, the participation of the Minor Child in the General Convention

Youth program sponsored by the Diocese in connection with the General Convention of

the Protestant Episcopal Church of the United States of America at the Anaheim

Convention Center, Anaheim, California, July 6-17

, 2009. The undersigned parent

further agrees that any or all of the material recorded may be used, in any form, as part of

any future production(s) made by or for the Society or the Diocese, and further, that such

use shall be without payment of fees, royalties, special credit, or other compensation to or

for the benefit of the minor child, parent, or any other person or entity.

________________________, 2009

Date

______________________________________

Parent/Guardian Signature

Necessary for all participants under the age of 18

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PARENTAL AFFIRMATION

I, ___________________________________, do hereby affirm to The Episcopal

Diocese of Los Angeles that I have the legal authority to provide my consent and

authorization for matters relating to the participation of

________________________________ in the Youth Program of General Convention of

the Protestant Episcopal Church of the United States of America in Anaheim, California

July 9-12, 2009.

Date: ________________________________________

Signed: _______________________________________

Relationship to child: _____________________________

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WAIVER AND RELEASE

I, _______________________________________ , Parent/Guardian, on behalf of

____________________________________(“Participant Minor Child”) do hereby

release, waive, discharge, covenant not to sue and agree to hold members of the

Episcopal Diocese of Los Angeles, its officers, directors, employees, representatives,

agents and affiliates, assigns and successors and the staff of the General Convention

Youth Program from any and all claims, demands and actions of any and every kind

directly or indirectly arising out of or relating in any respect to the participation of the

Participant Minor Child in the Youth Program of General Convention of the Protestant

Episcopal Church of the United States of America in Anaheim, California July 6-17

2009. My waiver and release of all claims, demands, actions and liability shall include

without limitation, any injury, illness, death, property damage or loss to the Participant

Minor Child which may be caused by any act, or failure to act by the staff of the General

Convention Youth Program or sustained before, during or after the General Convention

Youth Program unless such injury, illness, death, property damage or loss is a direct

result of the willful misconduct of either the Diocese or the staff of the General

Convention Youth Program.

I understand that, without limitation of the foregoing, neither the Diocese of Los Angeles

nor the General Convention Youth Program shall be liable and each is hereby released

each from all claims that may arise from loss or damage to the Participant Minor Child’s

personal property or the interruption of the General Convention’s Youth Program for

whatever reason. Neither the Diocese of Los Angeles nor the General Convention Youth

Program shall be responsible for any lost or stolen property of the Participant Minor

Child or any persons attending day activities thereof.

Date: _________________________, 2009

_______________________________________________________

Parent/Guardian Signature

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MEDICAL CONSENT FORM

To Whom It May Concern:

We (I), the undersigned, do hereby give permission for our (my) child

__________________________________ to attend and participate in the General

Convention Youth Program in Anaheim, California, July 9-12, 2009.

We (I) authorize an adult, in whose care the above named minor has been entrusted by us

or by a staff member of the General Convention Youth Program, to consent to any

reasonably necessary medical examination, anesthetic, medical, surgical or dental

diagnosis or treatment, and/or hospital care, to be rendered to the above named minor

under the general or special supervision and on the advice of any physician or dentist

licensed under the provisions of California law and an active member of the medical staff

of a licensed hospital, whether such diagnosis or treatment is rendered at the office of any

such physician or any such hospital, clinic or urgent care facility.

We (I), the undersigned shall be liable and agree to pay all costs and expenses incurred in

connection with such medical and dental services rendered to the aforementioned child

pursuant to this authorization.

We (I) understand that should it be necessary for our (my) child to return to my care due

to medical reasons or otherwise, that I shall assume all transportation costs.

________________________________________________________________________

______

PLEASE FILL OUT THE FOLLOWING INFORMATION

Do you have hospital insurance?

Yes

No (please check one)

Insurance Company:_______________________________

Policy Number:______________________________

Please list any allergies, medical problems, current medications, etc. you think would be

important for us to know about*:

________________________________________________________________________

please note that there is a more complete heath history that must also be completed

Date:______________________, 2009

Parent(s) Signature:_______________________________

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Medication Form

NAME OF STUDENT:

BIRTHDATE:

DIAGNOSIS:

MEDICATIONS:

If medication is given on an as-needed basis, specify the symptoms or conditions when medication is to be

taken and the time at which it may be given again.

DOSAGE TO BE GIVEN DURING PROGRAM: TIME(S) OR INTERVAL BETWEEN TIMES TO BE

GIVEN:

If the student is taking more than one medication, list sequence in which medications are to be taken

__________________________________________ ___________________________

______________________________________________________________________

Physician Name (Print or Type) ____________________________________________________________

Physician Signature: _____________________________________________________________________

Parent or Guardian Name (Print or Type)____________________________________________________

Parent or Guardian Signature _____________________________________________________________

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FIELD TRIP PERMISSION

I, _______________________________________ , Parent/Guardian, on behalf of

____________________________________

give permission for my minor child

to participate in General Convention Youth Program activities taking place off site from

the Anaheim Convention Center, Anaheim, California. I understand that transportation to

and from these activities will be provided for my child by the General Convention Youth

Program. I understand that the field trips are part of the General Convention Youth

Program and if I choose to not have my student participate in one or more off site

activities, that other care arrangements will need to be made by me for my student during

the times of that field trip activity.

Date: _________________________, 2009

_______________________________________________________

Parent/Guardian Signature

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ELECTRONIC DEVICE POLICY

Electronic Devices: i-Pods, MP-3 players, PSP players, cell phones, cameras and other types of

electronic equipment may not be used during regular group time. They will be able to be used

during free time. The General Convention Youth Program will not be held responsible for any

theft or loss of the above mentioned electronic devices.

I have discussed this policy with my student ___________________(student’s name) and

understand that any loss will be our responsibility.

Signed (Parent/Guardian) __________________________________________________

Date ____________________________________

I have discussed this policy with my family and understand that any loss will be my responsibility.

Signed (Student)_____________________________________________________________

Date______________________________________

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Today's Date:

Student’s health history – parent’s report

STUDENT’S Name (Last, First, M.I.):

Check one: Male_____ Female______

DOB:

PARENT/GUARDIAN

DOES PARENT/GUARDIAN LIVE IN HOME WITH CHILD?

PARENT/GUARDIAN

DOES PARENT/GUARDIAN LIVE IN HOME WITH CHILD?

IS/HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN:

Date of last physical exam:

HEALTH AND DEVELOPMENTAL HISTORY

Childhood illness: Circle any that apply

Measles

Mumps

Asthma

Chickenpox

Rheumatic Fever

Hay

Fever

Diabetes

Epilepsy

Whooping Cough

Poliomyelitis

Ten- Day

Measles (Rubeola)

Three-Day Measles (Rubella)

Other_____________________________________________________________

Immunizations and dates:

Tetanus

Pneumonia

Hepatitis

Chickenpox

Influenza

MMR Measles, Mumps, Rubella

Specify any other serious or severe illnesses or accidents

Does the student take prescribed medications?

Name the Drug

Strength

Frequency Taken

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Does the student have any allergies to medications?

Name the Drug

Reaction

Does the student use any special device(s)? (i.e. hearing aids, nebulizer,

cochlear implants, etc)

Name the Device

Reason for use

Does the student use any special device(s) at home? (i.e. nebulizer,

orthodontic appliances, etc.)

Name the Device

Reason for use