Polk City UMC Child/Youth Parental Consent Form
One form per child is required to be updated each year following the initial submission.
Email *
Section 1: Child/Youth Information
Child/Youth's Name *
Birthdate *
MM
/
DD
/
YYYY
Grade
Clear selection
Address *
Youth's cell phone
Youth's email
Please list any food, drug, or other allergies. Please note if epi-pen is carried. (If none, say "none.") *
Please list any health, learning, or behavioral details of which we need to be aware and/or accommodations that may help your child be successful at children's/youth activities. (If none, say "none.") *
Parent/Guardian Information
Name of Parent/Guardian #1 *
Parent/Guardian #1 phone number *
Parent/Guardian #1 email *
Parent/Guardian #1 address if different than child's
Name of Parent/Guardian #2
Parent/Guardian #2 phone number
Parent/Guardian #2 email
Parent/Guardian #2 address if different than child's
Please list any custody or safety issues of which our staff need to be aware. (Please email melody.webb@polkcityumc.org if assistance is needed or to discuss this item in person.)
Emergency Contact and Medical Information
In the event of an emergency all efforts will be made to contact the parent/guardian of the child. In the event the parent/guardian cannot be contacted, the following person(s) will be contacted.
Name and phone number of Non-Parent/Guardian Emergency Contact #1 *
Name and phone number of Non-Parent/Guardian Emergency Contact #2
Family doctor name and phone number
Health insurance company
Health insurance policy number
Health insurance policy holder name and birthdate
Consents
Please provide your electronic signature to indicate your agreement with the following statements.
I have legal custody of the student named, a minor, and am giving my consent for him/her to attend events organized by Polk City UMC. I understand there are risks involved in any event and I hereby release Polk City UMC, its pastor, employees, and volunteers from any and all liability for any injury, loss, or damage to a person or property during the course of my child's involvement with the organization. (Type electronic signature indicating agreement.) *
In the event my child is injured and requires medical attention, I hereby give consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event that treatment is required from licensed physician or hospital personnel, I agree to hold such person free and harmless of any claims of responsibility for the cost of any medical care not reimbursed by my insurance provider. (Type electronic signature indicating agreement.) *
I hereby give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending activities sponsored by Polk City UMC. I hereby agree to bring my child home from any event at my own expense should they become ill or if deemed necessary due to my child's behaviors or actions. (Type electronic signature indicating agreement.) *
Occasionally the church takes photo and video during events for use on official church social media account, newsletters, and/or website. Please check the box indicating your consent to have your child's photo posted on these official platforms only. *
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