Marietta First United Methodist Church Youth Ministries Consent And Waiver Form printable pdf download

Marietta First United Methodist Church Youth Ministries

Consent and Waiver Form

Name of Student/Participant_________________________________________

Member of MFUMC

Yes

Address__________________________________________________City/State___________________Zip_________

Date of Birth (MMDDYYYY)___________________ Home Phone _________________

Medical Insurance Co.________________________________________Policy#______________________________

Mom’s Name _________________________________ Mom’s Email Address ______________________________

Mom’s Work #_________________________________Mom’s Cell #______________________________________

Dad’s Name ___________________________________Dad’s Email Address________________________________

Dad’s Work # _________________________________ Dad’s Cell # _______________________________________

Functions and Activities

I give my permission for my above named student to attend and participate in activities, programs, and trips sponsored by

Marietta First United Methodist Church from August 2013 to August 2014 (unless otherwise noted in a separate permission

form). Prior to my participation or the participation of my student, I acknowledge that there are certain risks associated with

these activities, including, by way of example, physical injury due to activity-related accidents, and physical injury due to

transportation-related accidents, illness or even death. In addition, I acknowledge that there may be other risks inherent in these

activities of which I may not be presently aware.

Release of Liability

By signing this parental Consent and Waiver Form, I expressly warrant that this student or participant named above is capable

of withstanding both the physical and mental demands of these activities. I also expressly assume all risks to the student or the

participant in the activities, whether such risks are known or unknown to me at this time. I further release the church and its

ministers, leaders, employees, volunteers and agents from any claim that my student may have or that I may have against them

as a result of injury or illness incurred during the course of participation in these activities. This release of liability is also

intended to cover all claims that members of the students’ or my family or estate, heirs, representatives or assigns may have

against the church or its ministers, leaders, employees, volunteers or agents from any and all claims arising from my

participation or as a result of injury or illness of my student or participant that occurs while participating in the above described

activities, programs, and trips from August 2014 through August 2015.

Permission to Use Photos, send Emails or Text Messages

I give permission for the church, whether that being ministers, staff, leadership and/or volunteers to use photos of my child in

church publications such as church newsletters, church website, or other church related needs. I also give permission for the

church to contact my child via emails and/or text messages as a means of communication other than just telephone calls. I

furthermore understand that the church will not use these means in an inappropriate way.

First Aid and Emergency Medical Treatment

I recognize that there may be occasions where the student named above, or I, if I am a participant, may be in need of first aid or

emergency medical treatment as a result of an accident, illness, or other health condition or injury. Every reasonable effort will

be made to contact the persons listed on the form. If unsuccessful in contacting the persons listed, consent/permission is hereby

given for treatment by a competent medical personnel. I authorize an adult, in whose care the student has been entrusted, to

consent to any X-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be

rendered to the minor under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such

diagnosis or treatment is rendered at the office of said physician or at said hospital. I understand that Marietta First United

Methodist Church does not carry accident or medical insurance on participants or volunteers and that my insurance company

will be used for such medical care expenses. In so doing, I agree to pay all fees and costs arising from this action to obtain

medical treatment.

(Please see other side for additional information)

Marietta First United Methodist Church Youth Ministries Consent And Waiver Form

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