subject_line
CLUB 45 Permission Form
First Methodist
1750 20th St.
Vero Beach, FL 32960
Participant Information
First Name
Last Name
Gender
M
F
Birth Date
+
Grade
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
School
Address
City
State
Zip
Home Phone Number
Cell Phone Number
Shirt Size
Grade Go Into?
Emergency Contact Person
Relationship to Participant:
Mother
Father
Guardian
Guardian
First Name
Last Name
Address 1
City
State
Zip
Home Phone Number
Cell Phone Number
Email Address
Insurance
Do you have insurance?
Yes
No
Insurance
Insurance Policy #
Group #
Name on Policy
Family Doctor
Dr. Phone #
Health History
Pre-existing or present medical condition
Allergies
Medication & Dosage
Any restrictions we need to be aware of?
Medical and Liability Release Statement: I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary. I understand that all ordinary safety precautions will be taken at all times by the First United Methodist Church Youth Group and its agents during all events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold First United Methodist Church of Vero Beach, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. Parent/Guardian_Signature:
Date
+
Transportation & Photo Release
Transportation Release: I give my permission to the bearer of this letter to transport my child to the program events sponsored by the First United Methodist Church of Vero Beach, for all programs that take place within Vero Beach, FL and immediate surrounding areas. My child is allowed to travel out of Vero Beach, FL with the FUMC Youth Group when I have been informed of the specific destination, duration of the trip, and intended event ahead of time. My child may ride on the FUMC bus or van to meetings at individual homes and on off campus events (specific information prior to trips is required). Parent/Guardian_Signature:
+
Photo Release (For use on FUMC Website only)
Yes
No