First United Methodist Church Children & Youth Registration Form

Parent/Guardian Information

Parent/Guardian Names

This address will receive a confirmation email

Additional Email

Address

Home Phone

Cell Phone 1 (Name of person and number)

Cell Phone 2 (Name of person and number)

Phone Number to Call First

Child/Student Information

Child 1

Full Name (First, Middle, Last)

Preferred Name

Date of birth

Current School

Please tell us about any allergies and/or special needs

Child 2

Full Name (First, Middle, Last)

Preferred Name

Date of Birth

Current School

Please tell us about any allergies/special needs

Child 3

Full Name (First, Middle, Last)

Preferred Name

Date of Birth

Current School

Please tell us about any allergies/special needs

Child 4

Full Name (First, Middle, Last)

Preferred Name

Date of Birth

Current School

Emergency Contact Information

Please list someone that we can get in contact with in the event that we cannot reach the parent/guardians listed.

Emergency Contact Name(s)

Phone Number

Alternate Phone Number

Medical Release

In the event of an emergency or non-emergency situation in which medical treatment is required as a result of participation with First United Methodist Church, (hereafter FUMC), every reasonable effort will be made to contact the persons listed above. If unsuccessful in contacting the persons listed, consent/permission is given for treatment by competent medical personnel. I also authorize the FUMC Staff to administer any prescribed medications necessary for my child's health/safety during any on-site or off-site events. In the event that an accident occurs and/or any medication is administered, I understand that I will be required to sign an incident report.

I, on behalf of my child(ren) and myself, hereby release and hold harmless FUMC and its constituents for any injury, illness, death or other accident that may occur during church sponsored activities. I also consent to my child/student being driven by adult volunteers over the age of 21, with proper background checks & driver history information on file with the church office.

I understand that FUMC does not carry medical insurance on people participating in their activities. I agree to provide my insurance information at the time of service for any medical expenses and I am aware that I may be billed by the medical provider for any expenses not covered by my insurance. I understand that if I do not have medical insurance that I am responsible for the payment of any medical bills. I understand that it is my responsibility to communicate any changes to this information.

By typing my name and date below, I acknowledge that I have read and agree to the above medical release.

Name

Date

Media Release Opt-Out (Optional)

By checking this box, I specify that I would NOT like photographs or video footage of my child(ren) on the website or in other church publications. Do NOT publish pictures of my child.

Medical Information (Required Grades 4-12)

Insurance Company

Insurance Phone Number

Insurance Address (Street/PO Box, City, State, Zip)

Policy Holder Name

Policy Holder Insurance ID#

Doctor's Name

Doctor's Phone

Doctor's Address

For each child, please list the date of last tetanus shot and any medications he/she cannot take

Year-Long Authorization

Parents/Guardians, please note that YOU will need to be responsible for informing the supervising staff member of any changes to the medical or emergency contact information throughout the year.

In signing the below year-long authorization, I understand that I am giving my permission as parent/guardian for my child(ren) to participate in church sponsored events both on and off site for the entire year, effective August 2019-August 2020. I am also confirming the accuracy of all information I have provided. If any accident should occur due to medical or personal conditions not listed, I recognize that this is my responsibility and will not hold FUMC and their constituents liable.

Signature of Parent/Guardian for minors or Student Participant age 18+

Date

First United Methodist Church Children & Youth Registration Form

Description

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