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) *
Date of Birth *
Full Address *
Student Phone #
Parent or Guardian Name (First and Last) *
Parent Phone # *
Additional Parent Name
Parent Phone #
Additional Emails (Student or Parent)
Other Emergency Contact Name (First and Last) *
Emergency Contact Phone # *
Allergies:
Medical conditions of which we should be aware:
Medications being taken:
Insurance carrier or plan name *
Group #
Insurance ID #
Carrier Address
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) *
Submit
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