Providence umc youth fellowship
Providence UMC Parental Consent and Medical Release Form
Signature of Participant and Parent Required to Participate in Children Ministry Activities
Participant Name: ___________________________________________________________ DOB: ____/____/______
Phone: (_______)________________ School for fall 2012: _______________________________________ Grade for fall 2012: ___________
Parent/Guardian Name:____________________________________ Name: __________________________________
Work Phone: ____________________________________________ Work Phone: _____________________________
Cell Phone(s): ___________________________________________ Cell Phone: ______________________________
Other Emergency Contact: _________________________________ Phone: ( )____________________________
My signature hereby gives permission for our (my) child to attend and participate in Helping Hands
sponsored by The Va.
from July 19 – July 20, 2012. ___________________________________________________________
OVER-THE-COUNTER MEDICATION RELEASE:
The following OTC medications that I circle indicate my
authorization of chaperons, who are not licensed medical professionals, to give my child said medication if requested by my child (other than those provided by me for my child’s use with written instructions on dosage time and amount). I understand that my child will not be given any more medication than what is listed and will not receive medication except as scheduled on the medication packaging as recommended. If I circle medications below, I agree to release Providence United Methodist Church, its affiliates, and anyone acting on behalf of the church for the event indicated above of any liability or harm as a result of my child’s ingestion of the indicated medications. If my child needs other medication than those listed below, and I have not sent these medications, I understand that I will need to be contacted and give verbal approval for the medications to be administered (except in emergency situations; information regarding emergency medical treatment procedures is found in the Providence UMC Parental Consent and Medical Release Form).
If the medication is not circled, it will not be given to your child without verbal consent from you.
In consideration of Providence United Methodist Church
allowing the Participant to
participate in ministry activities, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless Providence
United Methodist Church
, its directors, employees, volunteers and agents (collectively herein the “Church”) from any and all
liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature
whatsoever which may be incurred by the undersigned and the Participant while involved in the youth activities. We (I) the parent(s)
or legal guardian(s) of this Participant hereby grant our (my) permission for the Participant to participate fully in youth ministry
activities. (Off-premise trips require separate permission form and liability release). Furthermore, we (I) [and on behalf of our (my)
minor Participant(s)] hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of
participation in recreation and work activities involved therein.
The undersigned further hereby agree to hold harmless and indemnify said Church for any liability sustained by said Church
as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.
MEDICAL TREATMENT PERMISSION:
We (I) authorize an adult, in whose care the minor has been entrusted, to
consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization. This medical release is valid from August 01, 2008 to August 31, 2009.
EARLY RETURN HOME POLICY:
Should it be necessary for our (my) child to return home due to medical reasons,
disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.
***PLEASE ATTACH A COPY OF MEDICAL INSURANCE CARD***
Medical Insurance: YES _______ NO _______ Insurance Company: ______________________________________________ Policy/Group ID#: ____________________________________ Emergency Phone #s in case parent/guardian cannot be reached: ________________________________________________________________________________________________________ Allergies (list all food, seasonal, medical, etc): __________________________________________________________________ Medical Conditions (list all): ________________________________________________________________________________ Parent/Guardian Signatures ________________________________/_________________________________ Date ___________ Participant Signature______________________________________/_________________________________ Date ___________
The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the drug list (formulary) that is at the core of your prescription-drug benefit plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list,you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. PLEASE NOTE: The symbol * nex
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