Medical Release and Permission Form
Effective Dates: July 2019 to August 2020
Email address *
Youth Information
First and Last Name *
Your answer
Birthday *
MM
/
DD
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YYYY
School Name
Your answer
Year in School
Youth Email Address
Your answer
Street address, city, zip *
Your answer
Youth's Cell
Your answer
Mother's Name
Your answer
Father's Name
Your answer
Mother's Cell
Your answer
Father's Cell
Your answer
Additional Emergency Contact Name and # *
Your answer
Medical Information
Please fill in the Medical insurance information and medical history information. A copy of your current insurance card should be submitted to the youth pastor to keep on file. Please update this information each year or when there is a change.
Medical Insurance Co *
Your answer
Medical Insurance Policy # *
Your answer
Physician Name and Number
Your answer
Dentist Name and Number
Your answer
Medical History (describe any physical and/or psychological ailment, illness, weakness, limitation, disability, or condition to which your child is subject of which our staff should be aware and what action of protection is required). Include names of medications if any taken. Write "NONE" if there are no conditions we need to be aware of. *
Your answer
For your child's safety and our knowledge, is the youth a *
Does your youth have any allergies? (specify under other) *
Does your youth suffer from any of the following? (details can be added under other) *
Required
Date of last tetnus shot *
MM
/
DD
/
YYYY
Does your child wear *
Please list any major illnesses the youth experienced in the last year *
Your answer
Should this youth's activities be restricted for any reason? *
Photo release
I understand that if I give permission for my child's photograph to be taken and used at church and on the church website and/or Facebook page that my child's name will not be used for identification purposes.
I give permission for my child to be photographed during youth activities *
I give permission for photographs of my child to be used on church bulletin boards/power point slides *
I give permission for photographs of my child to be used on the church website *
Medical release and permission
Youth activities may include, but are not limited to: cookouts, boating, water skiing, swimming, basketball, roller skating, games in the park, soccer, ice skating, volleyball, softball, baseball, camping, skiing, hiking, biking, concerts, golfing, mini golfing, hayrides, Bible studies, indoor and outdoor games. If you desire for your child's participation to be limited for any event, please submit your wishes in writing to the youth pastor before the event. By signing below, you give permission for your youth to participate in all youth activities sponsored by Willoughby Hills United Methodist Church (WHUMC). This consent gives permission to seek whatever medical attention is deemed necessary, and releases WHUMC and its staff of any liability against personal losses of named child.

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by WHUMC. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release WHUMC, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the WHUMC, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.
Parent/Guardian Signature(s) *
Your answer
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