Permission/medical Release Form printable pdf download

Summerfield United Methodist Church

Permission/Medical Release

EVERY youth AND adult attending the events must have one of these forms completed and signed. Church

group leader should have access to all forms for the group in case of emergency. Review the information in the

behavior statement with your youth. Please type or print legibly. Youth under the age of 18 must also have

permission portion at the bottom signed.

Date of event: ____________________

Name of Event: ____________________________

Gender: _______ Male

_______ Female

Age: _________

Grade: ________

Name: ___________________________________

Home Phone: _____________________________

Address: _________________________________________________________________________________

Medical Insurance Company: ___________________________

Policy No.: ___________________

Name of Policy Holder: _______________________________

Relationship: __________________

Emergency Contact: __________________________________

Relationship: __________________

Emergency Phone No.: _________________________

Alternate Number: ___________________

Known Allergies: _____________________________________

Limitations? ___________________

Please list medications currently used or may take: ________________________________________________

Behavior Statement: I understand that this event is for the Christian nurture and growth of every individual in

attendance, and all instructions given by event staff or adult group leaders are for the safety and benefit of all

present. I will show respect for all in attendance, in particular those in leadership positions. I will not use any

tobacco (if a minor), nor alcohol or illegal drugs. I will not bring weapons of any sort. I will attend all sessions

of the event with my group. I will make every effort to show respect for the facilities being used, and leave all

facilities in the condition in which I found them, or better! I will observe the curfew set by my leaders. I will

wear clothing appropriate for a Christian event, including modest shorts, tops, and bathing suits. I recognize that

willful failure to comply with instructions can cause serious problems, and upon consultation with counselors

and staff, may result in immediate contact of parents to make arrangements for the youth to be returned home at

their own expense.

I have read the above paragraph and I agree to be responsible for my behavior in accordance with the

guidelines stated above. My parents and I understand that violation of the guidelines may result in my being

sent home.

Signature of person attending the event: ____________________________________________________

(Over)

Permission/medical Release Form