EHUMC Youth, Health, & Emergency Information, Liability Release, and Special Event Covenant Form 2024-2025

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Student name *

Student email address, if available

Student cell phone #, if available

Student date of birth *

YYYY

Grade & School that Student is attending (2024-2025) *

Expected HS graduation year of student: Class of ... *

Parent(s)/Guardian(s) name(s) *

Parent(s)/Guardian(s) Emails (Please list name by each email address.)

Best cell phone for Parent(s)/Guardian(s) (Please list name by each phone number.) *

Home address *

Health Insurance Company Name & Phone Number (or notate "none") *

Health Insurance Policy Number (or notate "none") *

Family Doctor and Phone Number (or notate "none") *

Please list any food allergies (or notate "none") *

Please describe any medical conditions (or notate "none") *

Please list any medications taken regularly (or notate "none") *

In case of an emergency, please provide 2 additional emergency contacts (Name, Relationship to Student, and cell phone #): *

Any other information that is important to share about Student (optional)

FOR COMPLETION BY STUDENT: I understand the need for me to be responsible at special events and to follow these specific guidelines for the safety of myself and others. (Please check off each box as you read through the list to show that you understand these guidelines.) *

1. I understand that I am to respect and honor the authority of adult leaders

2. I understand that Youth Ministries events are not the time or the place for inappropriate display of affection towards anyone.

3. I understand that I am to dress appropriately (no vulgar or profane logos, alcohol ads, or clothing that is too revealing or generally inappropriate).

4. I understand that I am to follow the schedule and to participate in all scheduled activities.

5. I understand the need for specific sleeping arrangements and I will honor the arrangements made.

6. I understand that I am to respect the property of the facility and the property of others.

7. I understand I am not allowed to possess or use any weapons, tobacco (including vaping), alcohol, or any type of drugs that are not prescribed to me by a medical professional.

For #1-#4: I understand that these actions will be confronted once and privileges will be taken away, if repeated.

For #5-#7, I understand that these actions will result in being sent home at my family's expense.

I will follow the above guidelines and Embry Hills United Methodist Church's ledaership. I understand the consequences if I choose not to follow them.

Required

Name of Student completing form *

FOR COMPLETION BY PARENT/GUARDIAN: I understand all of the above guidlines and safety procedures for students, as well as the potential consequences, if not followed. ~~~ In addition, I give my above named child permission to travel in transportation provided by Embry Hills United Methodist Church, Inc., and its staff, members, and volunteers, and grant permission for this same student to participate in the in the events of the Embry Hills United Methodist Youth Ministries. ~~~ I give permission for any adult chaperone representing EHUMC to act on my behalf if my child is injured or ill. I understand that I may be unable to be contacted in an emergency to grant specific permission to emergency medical care, and I authorize the adult staff and volunteers representing EHUMC to make such emergency medical decision on my behalf. ~~~ In consideration of Embry Hills United Methodist Church, Inc., providing transportation and supervision in conjunction with Youth Ministries events, I hereby hold harmless Embry Hills United Methodist Church, Inc., its staff, members, and volunteers, and for my heirs, executors, and assigns do release and discharge Embry Hills United Methodist Church, Inc., its staff, members, and volunteers from all claims, actions, demands, and compensation whatsoever which I may have now, or in the future, on account of or in any way growing out of the circumstances relating to scheduled events, except for gross negligence. I further declare that the terms of this release are contractual and not a mere recital. ~~~ I understand that by selecting "I Accept" using any device, means or action, I have read and fully understand this release. I further agree that my signature on this document (hereafter referred to as my "E-Signature") is as valid as if I signed the document in writing. *

I Accept

I Decline

Have you completed the Photo and Media Release Form for Minors *

Yes

No (please visit bit.ly/ehumcminormediarelease to complete)

E-Signature of Parent/Guardian completing form *

Date form completed *

YYYY

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