Bixby FUMC 2019
Youth Group Permission Form and Medical Release for Participation in
Youth Activities, Events, and Trips
*If an adult fill the form out as if you are the student
Email address *
Name of student *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Age *
Students' Email
Your answer
Address *
Your answer
Phone Number *
Your answer
School
Your answer
Grade Level *
Name of Parent, Guardian or Emergency Contact *
Your answer
Parent, Guardian, or Emergency Contact Phone Number *
Your answer
Work Number or Other Contact Number
Your answer
Additional Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
**This form is used for all events, overnight included, so please fill this out even if it is just for an outing
Describe Students Current Health Problems *
Your answer
List Current Medications (if applicable to event)
Your answer
Directions For Giving Medications (if applicable)
Your answer
Name of Physician
Your answer
Physician Phone Number
Your answer
List any factor or conditions that make it advisable to limit your child's activities
Your answer
Provide any other information we should know
Your answer
I/We give permission for___________to attend and participate in activities sponsored by Bixby FUMC. *
Required
I/We give permission for recordings, photographs, and/or video images to be taken for church purposes. *
Required
Insurance Company *
Your answer
Policy Number *
Your answer
Insurance Phone Number *
Your answer
Subscriber Name *
Your answer
Release of Liability
I/We hereby release, discharge, free, and hold harmless the Bixby First United Methodist Church, Pastor, Staff, and other chaperoning adult for all liabilities and claims of damage arising or resulting from this child's participation in this activity unless caused by willful and intentional conduct on part of the leaders or staff. Except for those limitations and conditions named above, I certify that this child is healthy and fit to participate in this activity. In the event emergency treatment is necessary, I hereby authorize that emergency medical and/or surgical care may be provided to this child during participation or travel to and from this activity. This care may be provided by the hospital, physician, or care provider selected by the leaders of this activity. If necessary, this child may be transported in a private vehicle to receive care.
**By signing here you agree that all information is correct and you agree to the release of liability
Digital Signature *
Your answer
Date *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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