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Northwest Hills UMC Medical and Transportation Release Form 2025-2026
Please fill out the following form for your youth (grades 6 - 12) to participate in youth ministry activities at Northwest Hills UMC during the 2025-2026 School Year and Summer of 2026.

Please note: While the form does include a transportation release, youth will only be transported by approved adult leaders in situations that parents have been informed of and agreed to in advance.  For example, if a youth were attending our 2026 MidWinter Retreat, that travel would be arranged ahead of time and agreed upon by parents of all youth attending.
Name of Youth *
Address *
Birth Date *
Grade *
Family Contact Information 
Please include contact information for at least one parent/guardian.
1.) Name of Parent/Guardian *
1.) Relationship to Youth *
1.) Address (if different from above)
1.) Cell Phone of Parent/Guardian *
1.) Email of Parent/Guardian *
2.) Name of Parent/Guardian
2.) Relationship to Youth
2.) Address (if different from above)
2.) Cell Phone of Parent/Guardian
2.) Email of Parent/Guardian
Emergency Contact Information

If Parent(s)/Guardian(s) cannot be contacted, name of additional person to contact in case of emergency


Name of Emergency Contact *
Relationship of Emergency Contact to Youth *
Cell Phone of Emergency Contact *
Email of Emergency Contact *
Medical Information
Helpful to have in case of emergency
Does your youth have any specific medical needs or allergies we should know about?
 *
Does your youth have any required medications or special foods we should know about? *
Insurance Information
To be used in an emergency
Health Insurance Company
Full Name of Insured
Full Name of Primary Cardholder
Birth Date of Primary Cardholder
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DD
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YYYY
Policy ID Number
Group ID Number
Customer Service Number (back of card)
Permission, Consent, and Release
Permission, Consent, and Release

I, the parent or guardian, by checking the box below, do hereby attest that all the information on this form is the most current available for my child (the “Participant”). I give my permission for the Participant to participate in the activities of Northwest Hills UMC. This includes all sponsored activities on or off the premises of Northwest Hills UMC, including any and all activities involving travel and/or lodging. This permission shall remain in effect until Sept. 1st, 2026.

I hereby authorize Northwest Hills UMC staff to administer the medications as listed above. In order for my child to receive necessary medical treatment from medical staff and/or physicians in a medical clinic or hospital in case of illness or injury, I hereby consent to and authorize the ministry staff to obtain and consent to medical treatment for such illness or injury during the activity or activities of Northwest Hills UMC. It is understood that this authorization and consent is given in advance of any specific diagnosis or treatment and is given to encourage those persons who have temporary custody of the Participant, in my absence, and medical staff to exercise their best judgment as to the requirements of such diagnosis or said medical treatment. This medical consent will remain effective until Sept. 1st, 2026. I understand that any and all medical expenses incurred are my responsibility and that the Participant is not covered by medical insurance provided by Sept. 1st, 2026.

I hereby give my permission for the Participant to be transported in any vehicle designated by any ministry leader designated by Northwest Hills UMC, and in whose care the Participant has been entrusted while attending and participating in an activity or activities of Northwest Hills UMC.

In consideration of Northwest Hills UMC here allowing my child to participate in activities referenced above, I agree to release and hold harmless Northwest Hills UMC, its officers, agents and/or designated leadership, from any liability to or responsibility for bodily injury, damage or illness to my child while participating in any youth athletic or social activity which may be directly or indirectly sponsored by Northwest Hills UMC. Further, I agree to indemnify and hold harmless Northwest Hills UMC, its officers, agents and/or designated leadership with respect to any claim asserted by or on behalf of my child as a result of bodily injury, illness, or damage.


 *
Required
Parent/Guardian Name *
Today's Date *
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