Children's Permission Form

PERMISSION IS REQUIRED TO PARTICIPATE IN THE children's PROGRAM:

Name of Child:

Nickname:

Sex:

Birth date:

School Attends:

Age:

Grade:

Church Currently Attending:

Address:

City:

Zip:

Emergency Contact Person

Parent/Guardians Names

Address (if different from student):

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Email:

Do you have health 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:

Family Doctor Phone #:

List any prescriptions your child takes on a regular basis:

List any special medical condition, illness, allergy, or other problem your child may have:

Medical and Liability Release Statement

I grant full permission to any physician or hospital to take any action deemed necessary in case of an accident or illness. I also grant full permission to transport my child in a church vehicle. All vehicles will be driven by properly licensed, United Methodist conference approved drivers. Parent/Guardian_Signature:

Photo Release:

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

Child Release:

Child will be released only to the custodial parent or legal guardian and individuals listed below. The following people will also be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason, the custodial parent or legal guardian cannot be reached. Please include the name, address and phone number or each individual:

Parent or guardian's signature:

Date: