A.1. CONFIDENTIAL YOUTH AND CAREGIVER INFORMATION
{Mother Advisor must have form A1 at all times
-
Must have form for every girl, including pledges. Update if Mother Advisor
changes, as needed or, minimally, annually. lf no changes sign and date below otherwise, complete a new form.)
Please complete this form os soon as possible and return to the Mother Advisor of the assembly. ln the event of ony chonge ol stotus or rclationshlp thqt moy olter this
authorization, pleose ask to complete a new form as soan os possible so thot we remain informed about any potefltiol sofety issues. ln an effart to prctect the
wellbeing of each Rainbow 6irl, we molntain o confidentiol file of contad informotion of fsmily names ond contact inforfiotion and those outhorized to transport the
youth to and
from Roinbow events.
Thls lntormotlon ts to be used by aduh ieaders
for
sale ond eltecl,lve
ammunlcatlon ond never rcleased to unautborlzed
lndlvlduals,
Youth's Name:
Home Address:
Parents or Legal Guardianr l{ames & Phone number
Alternate Phone Numbers:
Girl's Phone Number:
ln the event of emergency, who should be contacted?
Who is authorized to transport this youth to and from Rainbow events?
Who is restricted from transporting this youth?
Are there other safety concerns about which we should be aware?
Parent/Legal Guardian Signature
Updates: Sign and date below if there are no changes in the above information
Parent/Legal Guardian Signature
Date
Parent/Legal Guardian Signature
Date
Parent/Legal Guardian Signature
Date
- to be done yearly
2L
A.2. CONSENT
FOR
ACNVIW OR TRIP & TRANSPORTATION
MA keeps and has at all times as well as the emergency medicalform. This form is intended to be a generic consent form for
all activities and transportation pursuant thereto. This form must be up dated as needed, or at a minimum, yearly.
Thls form ls requlred for Grand Assembly
Date:
Consent is eood for one (11 vear from this date
Youth Name:
Age:
Parents/Legal Guardians:
Address:
Work/CellPhone:
Home Phone:
Other Phone:
ln case of emergency, notifu:
Check all that apply:
I
D
O
O
for my
give
permission
for my
I
I give permission for my
I give permission for my
n
I
give permission for my daughter to be transported by any approved Rainbow adult
tr
I
give permission for my daughter to be transported only by the following:
I give permission
daughter
daughter
daughter
daughter
to participate
to participate
to participate
to participate
in all assembly events,
in all district events.
in all statewide events.
in Grand Assembly.
Authorized Slgnature:
Parent or Legal Guardlan
Date
Eoch Grond lurisdidion ls responsible for developing ond diitributing wrltten policies for those attending events to follow regarding safety, occeptoble behovlor, ond
trovel ln dnd oraund the areo of the evenL 6irls should never trovel olone and should olways be occompanied by on adult any time they leove the immediate area of
the event.
An Encrgcnty lnfocmatlon aN Medlcrll Autlprlntlon lorm should accompony thls con*nt fom lor coch event.
22
A.3. EMERGENCY INFORMATION ANd MEDICAL
AUTHORIZATION
{Pl of 2}
Mother Advisor must have this form at all times. This form to be
used by adults and girls. Must be shown at Grand Assembly
Date of Birth:
Member Nams:
This form is for all Rainbow events approved by the Assembly Rainbow Advisor Board for the calendar year of:
Contacts
Relationship:
Primary Contact:
Address:
Primary Phone:
Secondary Phone:
Alternate Contact:
Relationship:
Address:
Secondary Phone:
Primary Phone;
Alternate Emergency Contact:
Secondary Phone:
Primary Phone:
Regular Doctor Name and Contact information:
INSURANCE INFORMATION
Carrier:
Phone Number:
Policy Number:
Address:
Name of Policy Holder:
EMERGENCY AUTHORIZATION
I hereby give my permisslon to authorlze emergency medlcal treatment
for my daughter ln the event of lniury or illness durlng the above-
referenced event. The health care provlder ls authorlzed to perform necessary emergency medlcal sewices upon consent of the adult in charge
Assembly, IORG.
from the
Signature of Parent/legal Guardlan
Date
Pleose complete both poges
23
A.3. EMERGENCY INFORMATION and MEDI€AI AUTHORIZATION (P2 ot 2l
NAME
MEMBER
(required|
MEDICAT INFORMATION
Note all conditions which apply to your daughter. 6ive specific couse of ollergies and applicable speciol medical informotion.
AllerEies
Chronic/Recurrlne lllnesses
Drugs/medications:
Food:
lnsect Stings:
Epilepsy:
Hay Fever:
Poison lvy:
Ear lnfections:
Other:
Other:
Physical Limitations:
Date of Last:
Health Examination:
Tetanus Shot:
MEDICATION AUTHORIZATION
No Rainbow Girl shall keep medication in her possession. All medications must be turned in to the odults in charge.
o
The adults in charge have my permission to dispense the following medications to my daughter:
Medication
o
Name
Dosaee
Frequencv
Aspirin-free NSAIDS (Non-steroidalanti-inflammatory drugs such as Tylenol) may be administered to my daughter:
YES NO
lf yes, amount and frequency:
I
certify that all of the above information is correct.
Signature of ParentlG uardian
Date
Pleose complete both poges
24
A.9. ACKNOWTEDGEMENT AND AGREEMENT TO
CODE OF CONDUCT
{Youth Protection Guidelines for Jurlsdictions and Assemblles}
INTERNATIONAL ORDER OF RAINBOW FOR GIRTS
will
safeguord Rainbow Girts ond their odult leoders, the fotlowing guiilelines have been implemented' Abuse in ony fom
guldelines
is ta
prevention
in these
not be condaned by The tnternational order of the Rainbaw for Girts. An emphasis on sexuol abuse
dssert to any perpetrotor who moy be attracted to our members that such behavior will not be tolerated.
Approprlate admlnlstmtlve and legal adlon wlll be taken as warranted,
ln
order
to
I have read and agree to abide by this Code of Conduct.
I understand that the lnternational Order of the Rainbow for Girls will not tolerate abuse of its members,
and I agree to comply in spirit and in action with this position'
put forth in the full Youth
I fully understand that I am subject to the Code of Conduct, as well as allelements
protection policy of the lnternational Order of the Rainbow for Girls, and that any behavior or action in
violation of those policies will be grounds for my removal from the organization and loss of any awards or
designations I may have received during my involvement.
Sionature
Dote
Witness
Title
Thts form
-
Is requlred to be completed and slgned by every adultworklng wfth Rolnbow youth ln any capoclV.
33
Ohio Grand lssembly
lnternational Order of the Rainbow for Girls
General Photogra,'ph/yideo Release
ind
P}rotograph lnformation
Pictures are taken for the purpose of promoting the lnternational Order of the Rainbow for Girls {IORG}
via print and internet media, such as the Ohio Grand Assembly website, assembly Facebook, Rainbow
newsletters, assembly scrapbooks, newspaper articles, promotional posters or brochures, and official
IORG websites. Full names or contact information of minors will not be posted on websites or print
media.
I hereby give permission to the Ohio Grand Assembly, IORG, and any subordinate assembly to use the
below named individual's photo or video for Rainbow promotional purposes. These uses include, but
are not limited to lllustrations, bulletins, exhibltions, videotapes, reprints, reproductions, publications,
advertisements, and any prcrnotional or educational rnaterials in any medium now known or later
developed, including the internet. Photos of Rainbow activitles will be stored and kept for futune use
under these guidelines. Photos may be used without specific notlfication to those pictured in the photo.
Girl's
Name
Assembly
signature
Girl's signature (18 - 2Ol€ars old)
Date_
Parent/Guardian
Date
lt you N llOT llllSH l$ TO RELEASF your childs photograph please sign this below where indicated and
return it to the Mother Advisor of the assembly.
Girl's
Name
ParenVGuardian
Assembly
signature
Girl's signature {18
-
20 years old}
Please make a copy of this form for your records and mail the original or hand deliver
Mother Advisor:
Address:
slts/2o12
Date,
to: