REGISTRATION AND PERMISSION FORMS

Mid-South District Youth events and Youth Adult Committee meetings

Revised 2/2010

Event __________________________________________________Date _______________

Name:________________________________________________________________________________________

Address:_______________________________________________________________________________________

City:________________________________State:__________ Zip Code:__________ Phone:__________________

Email:____________________________________ Age:_______ Sex: ____________________________________

Health Insurance Name:__________________________________________________________________________

Health Insurance Policy #:________________________________________________________________________

Prescription medication(s) I must use:_______________________________________________________________

In case of emergency call please provide name, relationship and number:

_____________________________________________________________________________________________

Dietary restrictions/Allergies:______________________________________________________________________

RULES and COVENANT

We will all abide by our covenant.
We travel to be here together to build the beloved community based in our Unitarian Universalists
values. We will build our community upon the foundation and the vision of those who came before
us. We are grateful for the work that many have done so that we have this opportunity. We will add
our dreams and our hopes to the vision that is already here. We know we are important to
Unitarian Universalism, Mid-South District and our congregations. I will conduct myself
respectfully. I will respect others and I will expect others to be respectful of me. I will make room
for others to speak. I will listen deeply. I will speak my truth caringly. I will not engage in
community breaking behavior.

• No Drugs or Alcohol - including tobacco (unless they are listed above)

• No Weapons/Explosives
• No Violence/Bullying/Harassment
• No Sex – one person per sleeping bag - space between each sleeping bag
Anyone engaging in these behaviors will be sent home from the event.
• No Other Community Breaking Behavior
Anyone engaging in other community breaking behaviors could be sent home by the Spirit
Committee.
If the breakage of any of the rules or covenant is severe enough individuals may be band from
participation in MSD YAC youth events.
Parents Form – this must be filled out and come with each individual under 18 who
attends any MSD Youth event -otherwise they will not be allowed to attend.

I, ____________________________________________________, (please print) am the parent or legal guardian of

______________________________________________________, who will be attending. I hereby give my
consent and authority for the staff to take any reasonable action to help ensure the safety, health, and welfare of my
child. I also give my consent for any necessary medical treatment, including surgical care if it is needed. I further
understand that my child will be required to follow the rules of the meeting/event and site and live up to the
covenant; a breach of those rules may result in my child being disallowed to participate in the remainder of the event
and/or any future MSD Youth events. I agree to come and get my child if they break the rules.

My child (please check boxes below)

Has

Does not have

my permission to ride with a licensed adult advisor offsite during the event with advisor permission.

Has

Does not have

my permission to watch PG-13 and/or R rated movies that are pre-approved by the by the Deans and abide by our
covenant.

Signature of parent/guardian:__________________________________________ Date:_______________________

Questions: we love answering them!

Trustee for Youth
Scott Weaver
sweaver0529@gmail.com
(615) 513-9825
Education Director MSD UUA
Connie Goodbread
cgoodbread@uua.org
727-789-0448
727-772-3508
Participants and Adult Advisor Forms also must be filled out and brought to the event

I, ____________________________(participant), have read the rules and the covenant and

acknowledge them as my guide for participation in the MSD YAC and youth events. I understand
that if I break the rules I will be asked to go home and my parents will be called. If the community
breaking behavior I engage in is not listed specifically in the rules then I will abide by the decision
of the Spirit Committee, which could include my going home from the event with my parents or
possibly including the penalty of being disallowed to participate in the remainder events for a time
period that will be decided by the Spirit Committee.

Signature of participant:

___________________________________________________Date_______________________

I recognize that I am the advisor for ________________________________________ this MSD

YAC and youth event. I have read and signed the Advisor Code of Ethics and accept responsibility
for the youth in my delegation for the weekend. I have also read the Rules and the Covenant and
accept them as the rules that will be governing this event.

Signature of Advisor:

____________________________________________________Date______________________