VBS 2022

First Methodist Church

1750 20th St.

Vero Beach, FL 32960

Participant Information

First Name

Last Name

Completed Grade

Shirt Size

Address

City

State

Zip

Home Phone Number

Cell Phone Number

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

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 +

Photo Release

Photo Release (For use on FUMC Website only)

Yes

No