2018-19 School year Medical Release Form
Delphi United Methodist Church Form for current 6th to 12th grade students in Rock Solid Teen Ministry.
Student's First and Last Name *
Your answer
Student's Birth Date *
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Current School Grade *
Name of School attending *
Parent(s)/Guardian(s) First and Last Name(s) *
Your answer
Relevant Email for Parent/Guardian *
Your answer
Cell Phone for Parent/Guardian *
Your answer
Cell Phone for Student
Your answer
Student Address (for flyers, etc.) *
Your answer
In Case of Emergency, please share top 2 contacts and cell numbers. *
Your answer
In Case of Emergency where we cannot contact one of the 2 above, please list Doctor's name and phone contact *
Your answer
Any Allergies that we should know about? If yes, please explain. *
Your answer
Any Other Conditions that we should be aware of? If yes, please explain giving us more information such as treatments, signs, and symptoms, etc. *
Your answer
Statement of Release: All Teen Ministry sponsored activities conducted by Delphi UMC are carefully planned by the Youth Director and other youth leaders, whom are all mature adults. However, even with proper planning and precaution, unpredictable events can occur. By checking "I accept these conditions", the parent/guardian completing this form agrees to assume and accept all risks and dangers that may arise in Teen Ministry sponsored activities. The parent/guardian completing this form agrees to not hold Delphi UMC or any of its employees or volunteers liable for any damages, losses, or injures to the above named student. The Parent/Guardian completing this form also understand that their signature is both for medical and liability release. By checking "I accept these conditions", you are also giving consent and authorization for emergency transportation and any medical treatment deemed necessary by medical staff. As well, you are giving consent for any videos/photos of your child to be used for church promotion in print, church website or social media. *
Date this form completed and submitted. *
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