Microsoft word - bwyouthannualmedical.doc

CONFIDENTIAL Broadway United Methodist Church CONFIDENTIAL
YOUTH ANNUAL MEDICAL RELEASE AND PERMISSION FORM
You may complete this form online, print it out, sign it and return it to Children & Youth Ministries. This form MUST be renewed on, or before June 1st annually. If you need extra space for your answers, please use another sheet of paper and attach to this. DATE OF BIRTH
GRADE NEXT YR
HOME PHONE
CELL PHONE
EMAIL ADDRESS
SCHOOL ATTENDING NEXT YEAR
←PARENT OR GUARDIAN→
←NAME→
←HOME PHONE→
←WORK PHONE→
←CELL PHONE→
←EMAIL ADDRESS→
EMERGENCY CONTACT #1
IF PARENTS ARE UNAVAILABLE
EMERGENCY CONTACT #2
←NAME→
←RELATIONSHIP→
←HOME PHONE→
←WORK PHONE→
←CELL PHONE→
MEDICAL INSURANCE CARRIER
FAMILY MEDICAL DOCTOR
FAMILY DENTIST
MEDICAL OFFICE PHONE #
DENTAL OFFICE PHONE #
- MEDICAL HISTORY-
Student is permitted to take • Tylenol • Aspirin • Advil for headache: _____ YES _____ NO
Student allergic to ____________________________________________________________
Is student subject to motion sickness? ______ If yes, is student permitted to take Dramamine or other (please
list) motion sickness medication?___________________________________________________
Any other health concerns that the staff needs to be aware of? ________________________________________
Drugs and dosage currently taken _______________________________________________
Date of last tetanus shot: ________________________
Please list and explain any major illnesses the child experienced during the last year:
Should this child’s activities be restricted for any reason? Please explain (See note on other side):

Activities may include, but are not limited to: cookouts, boating, water skiing, swimming, basketball, roller skating,
rollerblading, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, downhill skiing,
snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides. Note: If you desire to limit your
child’s participation in any event, please submit your wishes in writing to the church youth director prior to that event.


-PARENTAL CONSENT #1-
(Insert Name of Student) _________________________________ has my permission to attend all youth activities
sponsored by Broadway United Methodist Church (hereinafter the “Church”) from June (Insert Year) __________
through May (Insert Year) __________. This consent form gives permission to seek whatever medical attention is
deemed necessary, and releases the Church and its staff of any liability against personal losses of named child.
I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for
him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved
in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and
volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur
during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of
a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the
event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to
hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such
consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the
cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health
insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be
in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should
they become ill or if deemed necessary by the Children and Youth Ministries staff member.

Parent/Guardian Signature: ________________________________________________ Date: __________________

-PARENTAL CONSENT #2-
Occasionally, Broadway UMC uses photographs of youth in print publicity such as newspapers, newsletters,
brochures, etc. and on the church website. No last names will be used on the internet. Please check one of the
options below and sign underneath:
___ I give permission for Broadway UMC to use my child’s picture and name in public materials.
___ Please do not use my child’s first name on the internet, but pictures are ok.
___ Please do not include my child’s picture in any publicity.

Parent/Guardian Signature: ________________________________________________ Date: __________________

Source: http://www.broadwayumc.net/PDF/BWYouthAnnualMedical.pdf