Annual Release Form 2022-23
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Student Information
First Name
Last Name
Student Email
Student Phone Number
Address
Birthday
MM
/
DD
/
YYYY
Grade you're in this year
School
Parent/Guardian Information
Name(s)
Email(s)
Cell Phone Number(s)
Insurance Information
Insurance Company
Policy Number
Group Number
Health Information
Do you have any allergies?
Any other food restrictions (vegetarian, vegan, etc.)?
Please list all medications being taken regularly.
Are there any special needs, conditions, or concerns we should know about?
Any limitations in activities by doctor or parent/guardian?
Additional Permissions
I give permission I give permission for photographs, video, or other images of the participant to be used by Church Street United Methodist Church for the website or other publicity, printed or electronic.
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I give permission for the youth staff of Church Street UMC to friend, follow, and/or otherwise engage with my child on the internet and specifically through social media sites if they already use them.
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I give permission for my child to receive these checked over the counter medications:
Parent/Guardian Permission
We, the undersigned parent/guardian, authorize permission for the above youth to attend all events and programming sponsored by Church Street UMC. We authorize any adult person to consent to any x-ray, medical, surgical, dental treatment, or hospital care. As parents/guardians we do hereby release, forever discharge and agree to hold harmless Church Street UMC, Jenny Cross (Youth Director), other church staff, and other adult chaperones of Church Street UMC from any and all liability which result from personal injury, sickness, or death. We assume all responsibility as result of participation in recreation and work activities involved with this event. Should it be necessary for our child to return home due to medical reasons, disciplinary action or otherwise, we hereby assume all transportation costs.
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Parent/Guardian Signature
Student Honor Statement
1. In everything I do I will attempt to honor God. I recognize that I am on these activities as a member of Church Street United Methodist Church and I will conduct myself in a way that is appropriate and glorifying to God and the church.

2. In everything I do I will attempt to honor those around me by what I say and how I act. I will treat others as I would like to be treated. I will have respect for other’s personal belongings and feelings. I will treat our church and anywhere you travel with respect and follow the rules and guidelines set by our leaders.  I will do everything I can to be an effective communicator with my leaders and peers.  I will also treat those around me with the utmost of respect. While on retreats, I understand that if I destroy or damage any property I may be sent home at my parents expense and am responsible for the cost of any damage along with my parents.

3. In everything I will attempt to honor myself. I recognize that I am a child of God and will respect myself and honor God in every way I can. I understand that the use of tobacco, drugs, alcohol, and firearms are illegal and forbidden on any and all youth trips. Possession will result in being sent home at my parents expense. I understand that the chaperones have the right to search my belongings if deemed necessary. I also understand that it is forbidden for boys to be in girl’s sleeping areas and girls in boy’s sleeping areas on overnight retreats and events.

4. I also understand that not all situations are covered in this form. I agree to abide by the guidelines set down by the adults on each trip as they deemed necessary. I understand that some rules are set on an as needed basis and are for the good of the group and its individuals.

5. Finally I understand that this form applies to all events and trips that we will take until August 2023. With my signature I am saying that I agree with the policies for the entire summer.

I have read this statement and faithfully promise to abide by it. I understand should I not abide by it, I will be responsible for my actions and accept any and all consequences.
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Student Signature
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