Medical Information / Consent Form
Effective for a full year from the date of completion.
Student's Name: *
Your answer
Date of Birth: *
MM
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DD
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YYYY
Gender
Street Address: *
Your answer
City: *
Your answer
Zip Code: *
Your answer
Home Phone:
Your answer
Cell Phone:
Your answer
Guardian/Mother's Name: *
Your answer
Guardian/Mother's E-mail:
Your answer
Guardian/Mother's Home Address:
Your answer
City:
Your answer
Zip Code:
Your answer
Guardian/Mother's Home Phone:
Your answer
Guardian/Mother's Work Phone:
Your answer
Guardian/Mother's Cell Phone: *
Your answer
Guardian/Father's Name:
Your answer
Guardian/Father's E-mail
Your answer
Guardian/Father's Address
Your answer
City:
Your answer
Zip:
Your answer
Guardian/Father's Home Phone:
Your answer
Guardian/Father's Work Phone:
Your answer
Guardian/Father's Cell Phone: *
Your answer
Emergency Contacts (Other than parents):
Contact #1 Name: *
Your answer
Relationship to participant: *
Your answer
Primary Phone Number: *
Your answer
Alternate Phone Number
Your answer
Contact #2 Name: *
Your answer
Relationship to participant: *
Your answer
Primary Phone Number: *
Your answer
Alternate Phone Number:
Your answer
Consent & Certification:
I, being the parent or legal guardian of the child/youth named above, do hereby consent to the participation of my child/youth in all of the regularly scheduled activities at Aldersgate United Methodist Church, of Nixa, MO, including field trips, camp-outs, swimming, boating, hiking, sporting events, retreats, camps and any other activities customarily associated with youth ministries. Further, I certify that my child is physically fit and adequately trained to participate in such events, including swimming, except as noted below:
Exceptions:
Your answer
Emergency Information & Consent
THIS CONSENT FORM GIVES ALDERSGATE STAFF AND/OR VOLUNTEER YOUTH WORKERS PERMISSION TO SEEK WHATEVER MEDICAL ATTENTION IS DEEMED NECESSARY FOR THE WELFARE OF THE CHILD AND RELEASES THE CHURCH AND ITS REPRESENTATIVES OF ANY LIABILITY AGAINST PERSONAL LOSS OF THE NAMED CHILD/YOUTH.

I/We, have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/we understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, 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 inured 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 Church, 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 provide below 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. I understand that I will be notified in the case of a medical emergency involving my child/youth.

I agree to notify the church in writing in the event of any health changes that would restrict my child/youth’s participation in any normal youth activities. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child/youth.

Preferred Hospital:
Physician's Name: *
Your answer
Physician's Phone Number:
Your answer
May your child be given pain relievers (such as Tylenol, Motrin, etc.)?
Date of last Tetanus shot:
MM
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DD
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YYYY
Please list any allergies, current medications or other factors that may impact participant during activities or emergency medical treatment continue on back if needed. (antibiotics, bee stings, foods etc.)
Your answer
Photo/Video Release
Please select:
Insurance Information
Health Insurance Company
Your answer
Policy Number
Your answer
Signature/Authorization
I certify that I am the parent or legal guardian of the participant.
Name of parent or legal guardian completing the form: *
Your answer
I can be contacted in the following ways:
Please select all that apply
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