Permission/Medical Release Form Each person attending an event must have and updated permission form completed by parent. Church leader will have access to the forms at all youth events. Please complete the form below to be stored in our database.
Parent Signature*
Date of Event
Name of Event
First name*
Last name*
Date of Birth
Current Grade*
Address*
Phone Number*
email address*
Male   Female   
Parent/ Guardian Name, Address, Phone #*
Medical Insurance Company
Policy Holder
Policy Number
Relationship to policy holder
Emergency Contact
Relationship
Emergency phone number
Alternative Emergency Phone #
Allergies?
Limitations
Medications
Youth: I have read and understand the Behavior Statement*Yes   
Parents: I give permission for my child to attend the above named event.*Yes   
I give permission for Center UMC and Summerfield UMC leaders to seek Medical attention for my child as necessary. I will not hold The United methodist Church, nor organizers/facility/staff associated in the event responsible in the event of accident, los*Yes   


Behavior statement I understand that is event is for the Christian nurture and growth of every individual in attendance, and all instructions given by event staff or adult group leaders are for the safety and benefit of all present. I will show respect for all in attendance, in particular those in leadership positions. I will not use any tobacco (if a minor), nor alcohol or illegal drugs. I will not bring weapons of any sort. I will attend all sessions of the event with my group. I will make every effort to show respect for the facilities being used, and leave all facilities in the condition in which I found them, or better! I will observe the curfew set by my leaders. I will wear clothing appropriate for a Christian event, including modest shorts, tops, and bathing suits. I recognize that willful failure to comply with instructions can cause serious problems and, upon consultation with counselors and staff, may result in immediate contact of parents to make arrangements for the youth to be returned home at their own expense. I have read the above paragraph and I agree to be responsible for my behavior in accordance with the guidelines states above. My parents and I understand violation of the guidelines may result in my being sent home.

 

PERMISSION FOR MINORS: I hereby give permission for my child_______________________________to attend the above named youth event and participate in activities.

EMERGENCY MEDICAL CARE: In the event that _________________________________(person attending event) suffers any illness or accident requiring emergency hospitalization while at this United Methodist Church event, I hereby give permission for any necessary hospitalization. I hereby give permission to the physician selected to order x-rays, routine tests, and treatment for the health of the above named. I realize that every effort will be made to contact me and/or the contact person above in case of emergency. In the event that I may not be able to be reached in an emergency, I hereby give permission to a physician to hospitalize / secure proper treatment for / order injection or anesthesia for the above named. I will not hold the WNC Conference of The United Methodist Church, Center or Summerfield United Methodist Church nor any other organization/facility/staff associated with this event responsible in the event of accident, loss, or death.