Youth | Forms

Permission is required to participate in the youth program:

Name of Youth:

Date of Birth:

Address:

City, State

Zip

Student Home Phone:

Student Cell Phone:

Student Email:

Emergency Contact - Parent or Guardians:

Address (if different from student):

Home phone:

Cell Phone:

Work Phone:

Email:

Do you have health insurance?

Insurance: If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your child is at a youth activity.

Name of Insurance Company:

Policy #:

Group #:

Name on Policy:

Family Doctor:

Phone number:

Health History

Pre-existing or present medical conditions:

Name and dosage of any medications that must be taken:

Please list any allergies your student has, including allergies to medications:

Please check any conditions that apply to your student:

Any restrictions we need to be aware of?

Medical and Liability Release Statement

I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary. I understand that all ordinary safety precautions will be taken at all times by the First United Methodist Church Youth Group and its agents during all events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold First United Methodist Church of Vero Beach, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. Parent/Guardian_Signature:

Date:

Transportation Release

I give my permission to the bearer of this letter to transport my child to the program events sponsored by the First United Methodist Church of Vero Beach, for all programs that take place within Vero Beach, FL and immediate surrounding areas. My child is allowed to travel out of Vero Beach, FL with the FUMC Youth Group when I have been informed of the specific destination, duration of the trip, and intended event ahead of time. My child may ride on the FUMC bus or van to meetings at individual homes and on off campus events (specific information prior to trips is required). Parent/Guardian_Signature:

Date:

Photo Release:

I grant my permission for my child to be photographed and pictures to share online on the FUMC website. Parent/Guardian_Signature:

Additional Comments: