605 Universal Permission Form • First United Methodist Church

First United Methodist Church

605 Student Ministries Universal Permission Form

Medical Info, Contact Info, Photo Release

Effective Dates: September 1, 2024- August 31, 2025

A completed universal permission form is required for any youth in 6th-12th grades to participate in any FUMC sponsored youth ministry event outside of Sunday School and Youth Group. Once submitted, this form is kept on file until the expiration date above. Please Provide the Youth Director with any updated information as changes occur.

YOUTH INFORMATION

First Name *

Gender *

School Grade *

Email Address

Home Address *

Home City *

Home Zip Code *

Last Name *

Date of Birth *

School *

Cell Phone

Home Address Line 2

Home State *

PARENT/GUARDIAN INFORMATION

Parent Name *

Email *

Phone Number *

Address *

Please List all parent/guardian phone numbers in the best order to be reached. (Please specify phone type)

Parent Name

Phone

Address

NON-PARENT EMERGENCY CONTACT

Name *

Relation *

Phone *

Name

Relation

Phone

MEDICAL INFORMATION

Primary Care Physician

Physician's Name *

Date of Last Tetanus Shot

Office Phone *

Insurance Information

Medical Insurance Company *

Policy/Group ID# *

Phone

Policy Holder's Name *

Medication

Over-the-Counter Medication Permission:

Do you give permission for your child/youth to be given over-the-counter medication by church staff or approced volunteers as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth ministry event?

Permission *

Yes. I give permission for an adult youth leader to give my child approved over-the-counter medications as directed on an as needed basis to treat non-emergency medical conditions

No. Contact me or get medical help if my child has any minor medical concerns.

Parent Signature *

Medical Conditions

Please answer in detail if applicable or write N/A.

List any medical conditions of youth (asthma, knee injury, epilepsy, wears contacts, etc.) *

List any allergies, the severity, and type of reaction (drug/medication, food, environmental, etc.) *

Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for leaders to know. *

PERMISSIONS

Liability Release

In consideration of First United Methodist Church allowing the Participant to participate in youth ministry (Meetings, Activities, Events, Retreats, Lock-Ins, Trip. etc.), I, the undersigned, do herby release, forever discharge and agree to hold harmless First United Methodist Church, its pastors, directors, employees, volunteers, and teachers (collectively herin 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 youth activities. I, the parent or legal guardian of the Participant, herby grant my permission for the Participant to participate fully in youth ministry activities, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, herby assume all risk of accidental personal injury, sickness, death, dameage, and expense as a result of participation in recreation and work activities involved therin.

Medical Treatment Permission

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 speacial 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 agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned youth pursuant to this authorization.

Early Return Home Policy

Should it be necessary for my child to return home due to medical reasons, disciplinary action, or otherwise, the undersigned shall assume all transportation costs and responsibility.

Transportation Permission

The undersigned does also herby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone (21 years of age or older) while attending and participating in activities sponsored by First United Methodist Church. My child and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

Photo Permission

During youth ministry events, staff, or volunteers will sometimes take photos or video of youth participating in various activities. These images may be used by First United Methodist Church for online and/or print publications. Youth will not be idedntified by name in publications.

Photo Permission *

Yes. I give permission for my child's photos to be used as described.

No. I do not want such images published of my child.

PARENTAL CONSENT AND SIGNATURE

The undersigned does herby give permission for my child (Participant), to attend and participate in any of First United Methodist Church's youth ministry activities, events, and retreats during the period of September 1, 2024-August 31, 2025. I have read and filled out all state medical and release information above.

Youth's Name *

Parent Signature *

Parent Signature