Child/Youth Permission & Medical Information Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Gay Street United Methodist Church

18 North Gay Street

Mount Vernon, OH 43050

(740) 392-6626

www.mtvumc.org

Email *

Child's/Children's Name(s)
*

Name of Parent/Guardian filling out this form
*

Parents'/Guardians' Names
*

Child's/Children's Address
*

I give permission for my child(ren) to participate in all children's and youth group activities associated with Gay Street United Methodist Church.
*

Yes

Required

I give permission for my child(ren) to ride in vehicles driven by a responsible adult designated by Gay Street United Methodist Church to and from activities and outing associated with Gay Street United Methodist Church.
*

Yes

Required

I give permission for my child(ren) to be included in any photographs/videotaping to be used on church website, displays, bulletin boards or other approved media, including social media. (No names will be used to identify children.)
*

Yes

By clicking 'yes' I hereby release Gay Street United Methodist Church of Mount Vernon and all of its affiliated organizations, as well as their officers, agents, employees, and volunteers, from any and all claims demands, actions, or causes of action due to death, injury, or illness, in any way, arising from church activities including, but not limited to transportation to and from the event. I further agree that the financial responsibility for securing care, in the case of injury resulting from participation in church programs is a matter between the participant and his/her health care provider, and that Gay Street United Methodist Church cannot pay health care providers for treatment of any injuries. It is further agreed that the participant will assume all legal responsibility for their personal safety and actions while participating in the program and while traveling to and from the program activities.
*

Yes

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms