St. Paul's UMC Medical Release and Permission Form
Our youth groups, grades 6-12, plan a variety of activities at St. Paul’s Church and activities away from the facility. This form gives permission for your youth to participate in all youth activities sponsored by St. Paul’s UMC. Information about planned activities will be provided through mass texts/emails, newsletters, announcements in worship, bulletins, the weekly e-mail, or on the church facebook page.
Email address *
Name of Student (First and Last) *
Your answer
Date of Birth *
Your answer
Full Address *
Your answer
Student Phone #
Your answer
Parent or Guardian Name (First and Last) *
Your answer
Parent Phone # *
Your answer
Additional Parent Name
Your answer
Parent Phone #
Your answer
Additional Emails (Student or Parent)
Your answer
Other Emergency Contact Name (First and Last) *
Your answer
Emergency Contact Phone # *
Your answer
Allergies:
Your answer
Medical conditions of which we should be aware:
Your answer
Medications being taken:
Your answer
Insurance carrier or plan name *
Your answer
Group #
Your answer
Insurance ID #
Your answer
Carrier Address
Your answer
Permission to Provide Necessary Treatment and Release:
I hereby give permission to the medical provider selected by the youth leaders to order tests, treatment, and release any records necessary for insurance purposes, and to provide related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the medical provider to secure and administer treatment, including hospitalization, for the person named above. I release St. Paul’s, youth leaders and helpers, and the United Methodist Denomination from any liability related to injuries incurred on this trip provided prudent precautions and practices of safety were followed. I also release St. Paul's Church to use pictures or video on church social media that contain my child in them.
Signature of parent or guardian or adult participant (First and Last, Date and Time) *
Your answer
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