701 Beach Drive NE

St. Petersburg, FL 33701

727.822.2031 Fax: 727.894.2971

LIFEGUARD (STUDENT MINISTRIES VOLUNTEER) PERMISSION FORM

Effective Dates: 9/1/09 to 8/31/10

Name ______________________________________ Age _____ Birthday ___________

ˆ Female ˆ Male Email _____________________________________________________

Address ______________________________ City__________________ Zip _________

Home Phone _____________________________ Cell ____________________________

Work Phone _____________________________

Emergency Contact: _______________________________________________________

Phone: Home _________________ Work _________________ Cell ________________

CONSENT TO EMERGENCY MEDICAL CARE

I hereby give my consent to any physician, emergency personnel and healthcare facility to provide

medical care to me, ___________________________________________, in the event of an

emergency. I give consent to transport by ambulance if the situation warrants it. In addition, I agree to
be financially responsible for any medical expenses that are incurred in treatment.

Physician ________________________________ Phone _________________________________

Dentist _________________________________ Phone _________________________________

Allergies ________________________________________________________________________

Date of last DPT or Tetanus shot ____________________

Are there any other medical or emotional considerations that we should be aware of?
_______________________________________________________________________________

Medical Insurance Company____________________________

Policy Number____________________________________
 AUTHORIZATION TO PARTICIPATE IN YOUTH ACTIVITIES
RELEASE AND INDEMNIFICATION
I understand that there are inherent risks involved in any youth activity or event in which the I
participate, whether on or off the premises of First Presbyterian Church of St. Petersburg (Church). I
desire to participate in Church sponsored activities for Youth, held on or off Church premises, and in
consideration of the my participation in and being provided transportation to said activities, I, the
undersigned, hereby release Church and its ministry staff, employees, members, volunteers or agents
from, and agrees to indemnify, defend and hold harmless Church and its ministry staff, employees,
members, volunteers or agents from and against any and all demands, claims, causes of action
(including any personal injury or damage to property), fines, penalties, damages (including
consequential damages), liabilities, judgments, and expenses (including without limitation attorneys'
fees) arising from or in connection with my participation in Church-sponsored activities whether
conducted on Church premises or off the Church's premises. The undersigned voluntarily and
knowingly executes this release and indemnity agreement with the express intention of extinguishing
the rights and obligations designated herein. I also agree to abide by the supervision and
transportation rules in accordance with Church policy. Additionally, unless I expressly deny the Church
authority to use photographic or other digital representations, I grant my consent to use the same by
the Church for any purpose, including display on Church authorized web sites.

COVENANT OF CONDUCT
In all meetings, retreats or other events under the sponsorship and/or guidance of the Church, I am
representing the Christian community and I am responsible for my actions. I understand the following
guidelines will be followed:
1. No use or possession of illegal drugs, alcoholic beverages and tobacco.
2. All conduct will respect property, one another, staff, adult leaders, schedules and event rules.
3. No fighting, weapons, fireworks, lighters or explosives.
4. No offensive or immodest clothing.
5. Participation with the group and in the activities is expected.
I, the above named Lifeguard, understand the above Covenant of Conduct and I agree to abide by it to
the best of my ability.

Lifeguard Signature ____________________________________ Date ____________________

I, as a Lifeguard, understand all three parts of this agreement. If I disregard the Covenant of Conduct,I
will be asked to leave the event.

Lifeguard Signature ____________________________________ Date ____________________

Print Name ____________________________________________

STATE OF FLORIDA, COUNTY OF ___________________________

The foregoing instrument was sworn to and subscribed before me this ____ day of ____________,

_____, by _____________________, who is personally known to me or who has produced

_________________________ (type of identification) as identification.

NOTARY PUBLIC, STATE OF FLORIDA