Medical Release and Permission Form

FIRST UNITED METHODIST CHURCH
MEDICAL RELEASE AND PERMISSION FORM
(Required prior to participation in any church-related trip or activity)
MINOR’S FULL NAME
________________________________________________________________________________
(Last)
(First)
(MI)
Birth date: _______/______/_______
Minor’s Social Security ________ /________ /_________
MINOR’S MEDICAL HISTORY
Allergies: ________________________________________________________________________
Current Medications: ______________________________________________________________
Date of Last Tetanus Shot: ________________ Other Medical Concerns: _____________________
________________________________________________________________________________
________________________________________________________________________________
MEDICAL INSURANCE INFORMATION
Insurance Company: _______________________________________ Phone: ________________
Policy/Group# : ___________________________________________________________________
Regular Physicians Name: __________________________________________________________
Primary Insured (parent/guardian): ____________________________________________________
PARENT/LEGAL GUARDIAN EMERGENCY CONTACT INFORMATION
Name: __________________________________________________________________________
Relationship to Minor: ____________________ E-Mail Address: ____________________________
Mailing Address: __________________________________________________________________
Street/POBox
City
State
Zip
Telephone: Home - _________________ Work - ________________ Cell - ________________
Place of Employment: ______________________________________________________________
Emergency Contact Person (other than parent/legal guardian)
Name: __________________________________________________________________________
Telephone: Home - _________________ Work - ________________ Cell - ________________
PERMISSION/HOLD HARMLESS FORM
As the custodial parent or legal guardian of the minor named above. I am aware of the
involvement and participation of this minor in activities at and excursions with First United Methodist
Church groups, staff, and adult chaperones. I request and authorize the staff and adult chaperones of
FUMC to exercise temporary custody and care of this, my minor child while on church-related events.
During such time as my child is in the care of the staff and/or adult chaperones, and in the event
that my child shall need medical treatment or care, including, but not limited to emergency surgery,
hospitalization, or other emergency or non-emergency medical care, I hereby authorize and consent to
such medical treatment and care that may be deemed necessary for my child, at my expense.
I shall be responsible for any and all costs or expenses of providing such care and treatment for
my child, and shall reimburse, indemnify, and hold harmless First United Methodist Church, its staff and
adult chaperones from same.
I further understand that it is solely my responsibility to provide the church with an updated
MEDICAL RELEASE AND PERMISSION FORM if any changes occur in the information provided above.
I understand that this form will remain on file at the church to be used for all events in which my child
participates.
BEFORE ME, THE UNDERSIGNED AUTHORITY PERSONALLY APPEARED:
Print Name: ______________________________________________________________________
Sworn to and subscribed this __________ day of _________________________, 20___________
Signature of Parent/Legal Guardian: __________________________________________________
Notary Signature) _________________________________________________________________
NOTARY PUBLIC, STATE OF FLORIDA, COUNTY OF POLK
NOTARY SEAL
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