Student's Name *

Nick Name

Birth Date *

Grade *

Gender *

Allergies

Physician's Name

Physician's Phone Number

Is there any other information that will help us when working with your student?

Parents’/Guardians’ Names *

Home Address *

Cell Numbers

Other Adults Authorized to Pick Up Student

By typing my name in this form below, I give my consent for my student listed above to participate in activities with First United Methodist Church (FUMC). I understand some events include transportation in vehicles driven by pre-screened adults. If my child is injured, I authorize FUMC to provide appropriate medical treatment up to and including a visit to a hospital if needed, and I understand I will be responsible for any treatment costs. I understand that photos of my student may be used to celebrate and promote events within the church, and may be posted online in formats such as Facebook and the FUMC website. *