Children and Youth Ministries

Medical Release & Registration Form 2006-2007

 

Name:                                                              Gender: Male              Female                        Birth Date:                 

 

Age                  School                                                                         Grade:                                                            

 

Address:                                                                       City:                                         Zip:                                         

 

Parent or Guardian(s):                                                                                                                                                

 

Home Phone:                                       Cell Phone:                                          Work Phone:                                       

 

Email Address:                                                                                                                                                

 

Please list two emergency contacts: (Adults other than parent or guardian(s))

Name                                                              

Phone                                                                                                                                                                                                               

Address ­­­­­­                                                                                                                                  

Relationship to Child                                      

 

Name                                                              

Phone                                                                                                                                                                                                               

Address ­­­­­­                                                                                                                                  

Relationship to Child                                      

 
                                            

 

 

 

 

 

 

Please list important Medical Conditions (Include allergies, medications, depression, behavior issues, etc.)

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           

 

Will your child bring medicine to activities? (including overnight activities)                     Yes                  No

If yes, for what?                                                                                                                                                            

Date of last Tetanus shot ____________

 

Doctor’s                                   Phone:                         Dentist’s                                               Phone:                        

Name:                                                                          Name:

 

Medical Insurance                                           Group Name                            Policy Number                                    

 

Medical and Liability

Release Statement

I give permission for my child to participate in First United Methodist Church sponsored events, (any known, advertised church program for children and/or youth).  I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed in this form.

I understand all reasonable safety precautions will be taken at all times by the staff at First United Methodist Church, and its agents during children’s and youth events.  I understand the possibility of unforeseen hazards and know the inherent possibility of risk.  I agree not to hold First United Methodist Church, their leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.

In the event I cannot be reached in an emergency during the activity dates shown on this form, I hereby give permission to the adult leaders at First United Methodist Church to act on my behalf with respect to my child’s health and safety while at or en route to and from activities.  I also give permission for a physician or dentist selected by First United Methodist Church and its agents to hospitalize, to secure medical treatment, and/or to order an injection, anesthesia, or surgery for my child as deemed necessary.

I accept full responsibility for any expense incurred while providing medical treatment for my child.  I understand that this medical release will be on file at 1376 Olive Street, from September 1, 2006 – August 31, 2007.

 

 

Signature(s) of Legal Parent/Guardian                                                                                                     


                                                                                                                                                           

Date__________________