2013 Conspire Student Conference 
                                                                          Discover an incredible life

Presented by St. Martin’s Youth Ministry

December 6-8, 2013

Participant Name_____________________________________________________ Grade____________ SSN_____________________________

Home Address________________________________________________________________________________________________________

Home Phone_____________________________________ Email________________________________________________________________

Parent/ Guardian Name(s) ________________________________________________________________Cell Phone_______________________

If unavailable in emergency, notify___________________________________________________________________________________________

Phone Number __________________________________________ Relationship____________________________________________________

I hereby give my permission for me/my child, _________________________________________ to attend St. Martin’s Episcopal Church Youth Ministry Conspire Conference. I (we) understand that in the event that medical treatment is required, every effort will be made to contact me/the listed emergency contact; however, if I/he/she cannot be reached, I give my permission to Anthony Orona, Laura Henry, Will Kulseth or Meredith Crawley, to secure any and all emergency medical care including anesthesia for me/my child in the event I/the emergency contact cannot be reached by telephone. I further agree to accept full responsibility for any accident or illness incurred by me/my child at this event, and I will not hold responsible St. Martin’s Episcopal Church, its officers, its staff, or any of the sponsors of this event for the accident or illness. In the event that I/the emergency contact cannot be reached by telephone I authorize St. Martin’s Episcopal Church staff, sponsors, officers of this event to contact Anthony Orona, Laura Henry, Will Kulseth or Meredith Crawley, who I have fully authorized and empowered any and all necessary decisions for my/my child’s well being. I agree to reimburse St. Martin’s Episcopal Church, its staff, officers, and sponsors of this event for the cost of any and all medical treatment for me/my child. I also understand that if I/my child is caught with alcohol, drugs, or any weapons of any kind, I/he/she will be sent home immediately at my additional expense. 

Indemnity and General Release

                Whereas, I, the undersigned, my child or children and/or my guest have registered to participate in the CONSPIRE CONFERENCE and other related activities from December 6-8, 2013 (the “Conspire Conference”) at St Martin’s Episcopal Church, 717 Sage Road, Houston, Texas 77056;

Whereas, I have agreed to provide this release and indemnity.

                Now therefore, premises considered, which premises form a part of this agreement, I _________________________________________ do hereby release, indemnity and hold harmless the Church, and each of its officers, vestry members, agents, employees, and clergy (collectively the “Church”) from and against any claim, liability (including negligence) or cause of action, including any claim, liability or cause of action relating to the negligence of the Church, relating directly or indirectly to any claim, cause of action or liability I, any child of mine, or guest of mine may have or assert against the Church relating to participation in any program or other activity, conducted in or relating to, the Conspire Conference.

Adult Participant, Custodial Parent or Legal Guardian Signature ___________________________________________________ Date_____________

Relationship to Participant________________________________________________________________________________________________

Allergies to medications and reaction________________________________________________________________________________________

Other Allergies________________________________________________________________________________________________________

Chronic/ongoing conditions ______________________________________________________________________________________________

Dietary Restrictions ____________________________________________________________________________________________________

Medications sent with participant___________________________________________________________________________________________
Prescribed medicines must be in original pharmacy container with correct name, date, instructions and physician’s name on label.

Are there any over the counter medications that the participant should not receive if any minor symptoms develop? (i.e. Tylenol, Advil, Kaopectate, etc.)________________________________________________________________________________________________________________

Insurance Co. _________________________________________________________________________________________________________

Insurance Ph#_____________________________________ Policy#_____________________________ Group#___________________________

– I have secured to this medical release a photocopy of both sides of my/my child’s insurance card.

Media Release

I hereby give my full consent to St. Martin’s Episcopal Church (SMEC) to record my/my child or children’s participation in any programs or events associated with the Conspire Conference. Further, I hereby transfer and assign to SMEC the exclusive rights to use and authorize others to use said images, video, and audio recordings for promotional and education use or resource sale in the future. I understand that his/her/their image may be used, but his/her/their name or personal information will never be shared publicly without additional, separate consent.

Adult Participant, Custodial Parent or Legal Guardian Signature ___________________________________________________ Date_____________

Relationship to Participant________________________________________________________________________________________________

Please return to Madeline Ligon, St. Martin’s Episcopal Church, 717 Sage Road, Houston TX 77056

Or fax to 713/622-5701 ATTN: Madeline Ligon