Parent/Guardian Name:
The undersigned, being the parent or legal guardian of (child's name) *
, and such child being under eighteen (18) years of age, does give permission for such youth to accompany the group and participate in the activities sponsored by First United Methodist Church (FUMC) and which may involve either traveling in church owned vans or buses or in other buses or private vehicles. This authorization shall be effective continuously from the date hereof until cancelled by written notice to FUMC.
I have the legal authority to sign this permission, release, and consent to medical treatment. I will keep informed of the church sponsored activities for my child. If I do not want my child to accompany the group and participate in any specific church sponsored activity, I will take sole responsibility to see that my child does not participate. *
I hereby release FFUMC, its staff, employees, drivers, sponsors and helpers from any liability for injury or damages suffered by the above youth and agree to release, indemnify and waive my rights by subrogation I may have, and hold harmless FFUMC, its staff, employees, drivers, sponsors, and helpers from injury or damages to my child. *
I can be reached at the following:
Home phone:
Work phone:
Mobil phone:
In case of an emergency, and the parent / guardian is not available, please indicate an emergency contact person:
Name:
Phone:
Other:
Are there any medical problems or special physical conditions or allergies of which we need to know?
If Yes, please explain:
I hereby consent and authorize the adult leader(s) accompanying my child to obtain emergency medical treatment in case of injury or illness upon presentation of this authorization or a photocopy thereof. *
Insurance Company:
Phone
Group Insurance Number
PPO/HMO?
Policy Number:
Full Name of Policy Holder:
Employer
Claims address of Company:
PLEASE UPLOAD A PHOTOCOPY OF YOUR INSURANCE CARD.
I give permission for my youth's picture to appear in newsletters, pamphlets, web page, etc. Please note that it is the responsibility of each parent, guardian, or managing conservator to update this information as the need arises.*
Date:
Complete your form by entering the letters you see below to help us know that you are a person and not a machine.