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Youth Mission Trip Release Form
June 4th-8th, 2023
Youth Name
(Required)
First
Last
Name Youth Prefers
Youth Gender
(Required)
Female
Male
Other
Specify Other
Youth Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Youth Phone
(Required)
Youth Email
Grade in August of 2023
(Required)
1st Parent Name
(Required)
First
Last
1st Parent Phone
(Required)
1st Parent Email
(Required)
1st Parent Address (if different from youth)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
2nd Parent Name
First
Last
2nd Parent Phone
2nd Parent Email
2nd Parent Address (if different from youth)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Alternate Contact
(Required)
First
Last
Alternate contact relationship to family
(Required)
Alternate Phone Number
(Required)
Release for photos and driving
(Required)
I give permission for photographs or video footage of my youth to be used by Saint Barnabas for promotional purposes. (brochures, website photos, etc.)
I give permission to be driven by the adult leadership of Saint Barnabas.
Insurance Company
(Required)
Group/Policy Number
(Required)
Allergies
Medications over the counter allowed to take
Medications Taken
Morning
Afternoon
Evening
Bedtime
Specify Morning Medication
Specify Afternoon Medication
Specify Evening Medication
Specify Evening Medication
Other
Glasses
Contact Lenses
Hearing Aids
Food Allergies
Gluten Free
Dairy Free
Vegetarian
Vegan
Select All
Specify Food Allergies
Cereals I like
(Required)
What I like to put on a sandwich
(Required)
Snacks I like
(Required)
Candy I like
(Required)
Consent
(Required)
As part of the Mission trip, I realize I have to:
• Live with some inconveniences (share a room with others, travel in a van,, no electronics, experience new things, etc.)
• Keep up with the other team members (i.e. cooperate with the sleep schedule & work schedule)
• Follow all adult leadership
• Have a positive attitude in every way and do whatever is best for all concerned
I will work faithfully with the Lord so that my life will be a witness for Christ to all those I have come in contact with while on the Mission Trip.
I agree to the statements above
Youth Read and Consent
(Required)
I understand that the Serving in the City Mission trip is organized and coordinated by the adult leaders. I agree to adhere to the established rules and guidelines that I have read through carefully. I also understand that failure to comply with the rules could result in being sent home at my parent’s or my expense.
I agree to the statements above
Youth Sleeping Guidelines
(Required)
1. I will respect and stay in my bed when asked
2. We understand that you may need to use the restroom, but that should be once and by yourself.
3. I will not talk and be disruptive to those around me during sleeping time.
4. In the morning, I will get up when asked and get ready right away.
I agree to the above guidelines
Youth Covenant
(Required)
Expectations
It is expected that everyone will abide by the rules and guidelines of this covenant.
1. Alcohol, tobacco, inhalants, fireworks, weapons (including knives) or illegal drugs of any kind have no place on any trip taken by our church and will not be tolerated.
2. We will respect the physical property of others (personal items) including the vans and cars in which we travel (using seatbelts at all times), places we may go, the churches in which we will be staying and using. If you mess it up…you clean it up, if you break it…you tell someone.
3. The language we use and our attitude need to reflect the Christian nature of our group. Be positive and reflect who we are as a Christian community in all we say and do! Profanity, abusive language, derogatory comments and put-downs have no place on our trip.
4. Everyone-youth and adults- will be expected to be present and on time for all events.
5. We are never to be off by ourselves. Make sure you always have others with you when you are out. The adults on the trip need to know where we are at all times.
6. Cell phones will be collected when you arrive and will be handed out when we are done on the last day before being picked up. Adult leaders will have their phones at all times, so if youth need to contact their families they may do so.
7. Listen to the adults and be polite to them!
8. We need to be in our beds by curfew, which will be decided by the adult leaders.
9. We encourage expressions of affection and caring. However, this trip is not a date. Even if you are with your “sweety” or you discover your “sweety” on this trip, expressions of romantic affection need to be appropriate to our trip. Do not put yourself in an embarrassing situation.
10. Everyone must wear t-shirts (that cover your stomach & have not been cut up). There are no exceptions to this! No “short” shorts. Our dress code will be t-shirts, jeans, longer shorts and tennis shoes.
11. Have fun, help others to have fun, and get to know others. Be considerate and kind to each other on the trip. Be flexible and patient with one another.
I agree to the above covenant
Parent Consent
(Required)
Expectations
It is expected that everyone will abide by the rules and guidelines of this covenant.
1. Alcohol, tobacco, inhalants, fireworks, weapons (including knives) or illegal drugs of any kind have no place on any trip taken by our church and will not be tolerated.
2. We will respect the physical property of others (personal items) including the vans and cars in which we travel (using seatbelts at all times), places we may go, the churches in which we will be staying and using. If you mess it up…you clean it up, if you break it…you tell someone.
3. The language we use and our attitude need to reflect the Christian nature of our group. Be positive and reflect who we are as a Christian community in all we say and do! Profanity, abusive language, derogatory comments and put-downs have no place on our trip.
4. Everyone-youth and adults- will be expected to be present and on time for all events.
5. We are never to be off by ourselves. Make sure you always have others with you when you are out. The adults on the trip need to know where we are at all times.
6. Cell phones will be collected when you arrive and will be handed out when we are done on the last day before being picked up. Adult leaders will have their phones at all times, so if youth need to contact their families they may do so.
7. Listen to the adults and be polite to them!
8. We need to be in our beds by curfew, which will be decided by the adult leaders.
9. We encourage expressions of affection and caring. However, this trip is not a date. Even if you are with your “sweety” or you discover your “sweety” on this trip, expressions of romantic affection need to be appropriate to our trip. Do not put yourself in an embarrassing situation.
10. Everyone must wear t-shirts (that cover your stomach & have not been cut up). There are no exceptions to this! No “short” shorts. Our dress code will be t-shirts, jeans, longer shorts and tennis shoes.
11. Have fun, help others to have fun, and get to know others. Be considerate and kind to each other on the trip. Be flexible and patient with one another.
As parent/guardian of the youth being registered, I agree to the above covenant