First United Methodist Church of Belmont
Emergency Information/Permission Form
Active dates September 6, 2018-August 31, 2019
Email address *
YOUTH CONTACT INFORMATION
Youth Last Name *
Your answer
Youth First Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Grade *
Required
School *
Your answer
Youth Cell Phone
Your answer
Can this student receive text messages from the Director of Youth Ministries, Youth Music Director & Youth leaders? *
Youth Email Address
Your answer
Youth Street Address *
Your answer
City, State and Zip Code *
Your answer
Youth Home Phone Number
Your answer
PARENT/GUARDIAN CONTACT INFORMATION
Name of first parent (who is to be contacted first when needed) *
Your answer
First Parent Cell Phone *
Your answer
First Parent Email Address *
Your answer
Name of Second Parent
Your answer
Second Parent Cell Phone number
Your answer
Second Parent Email Address (only include if you want this email added to the database)
Your answer
EMERGENCY CONTACT INFORMATION
Information informs us of who to contact if the First and/or Second Parent cannot be reached during the event of an emergency.
Contact in case of emergency (when parents cannot be reached) *
First and Last Name
Your answer
Phone number for emergency contact *
Your answer
YOUTH MINISTRY CONTACT INFORMATION
Please provide the preferred email address to be used for Constant Contact. This will provide you with weekly updates of the happenings in Youth Ministry.
Your answer
If so desired, include a secondary email address to be used for Constant Contact. This will provide you with weekly updates of the happenings in Youth Ministry.
Your answer
Please provide the preferred cell phone to be used for EZ text. This will provide you with last minute reminders or changes in Youth Ministry.
Your answer
If you desire, provide an additional cell phone to be used for EZ text. This will provide you with last minute reminders or changes in Youth Ministry.
Your answer
INSURANCE INFORMATION
Name of your Insurance Company *
Your answer
Policy Number *
Your answer
Group Number *
Your answer
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