This form is for us to verify that you aware and approve of your child’s participation at 18 South Youth Center.

Please call 717-347-8416 or email info@18south.org with any questions or concerns.  

Student Name *
Student Name
Put "none" if no concerns exist
Please include all of the information above for each additional student.
Parent Guardian Name *
Parent Guardian Name
Parent Guardian Name 2
Parent Guardian Name 2
Mother, Father, Grandmother, etc.
Address *
Address
Phone 1 *
Phone 1
Work/Home
Phone 2 *
Phone 2
Cell
Medical Authorization/Consent *
I understand that this form is effective from the date of February 1st 2019, through January 31st 2020, and it is my responsibility to report any changes in this information to 18 South at 717-347-8416. I understand that, in the event my student requires medical treatment while engaged in 18 South activities, reasonable efforts will be made to contact me. If I cannot be reached I hereby consent and give permission to the 18 South Youth Center staff to act as an agent for me, to consent to emergency medical treatment advised and supervised by a physician, surgeon, EMT, or dentist licensed to practice under laws of the state where services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all of my student’s medical allergies, medications being taken, medical problems and other pertinent information.
Permission for Participation *
I authorize my student(s) to attend and participate in all applicable events and activities of 18 South Youth Center, including off-site events. I understand that my child must obey all established rules for the event and follow the instructions of 18 South staff and volunteers. I acknowledge that my student(s) may be transported to and from events by 18 South Youth Center, including by staff and volunteers.
Media Release *
18 South Youth Ministries maintains a website and Facebook pages and we may post pictures and/or videos of 18 South activities. Pictures and/or videos may also be displayed on bulletin boards, PowerPoint presentations, flyers/brochures, and in outside publications such as local newspapers. Because your student’s image may be included in these pictures and/or videos, we must obtain your permission to post these pictures and/or videos. Although student’s names may be used in publications, no other personal information will be posted.
18 South Rules
In order for 18 South to be a safe, fun place for teens to connect with each other, with adults that care, and the God that loves them-we need everyone, parents and students alike to be aware of our rules. Please go over these key rules with your son/daughter and sign that you both understand and agree to abide by our guidelines. Failure to follow these rules will result in disciplinary procedures that might include a combination of suspension, expulsion, or service hours at 18 South. Respect: It is expected that all students will respect one another, all adults, and the 18 South facility. No profanity or abusive speech. Fighting, bullying or violent behavior will not be tolerated. Weapons, drugs, and alcohol are strictly prohibited. 18 South is for 7th-12th graders only.
Parent / Legal Gaurdian Name *
Parent / Legal Gaurdian Name
Date
Date