Youth Release Form | Thalia United Methodist Church

YOUTH RELEASE FORM

To be completed at the beginning of each school year or upon entry into the program

Step 1 of 4

PARTICIPANT INFORMATION
Participant's Name*
First Middle Last
Participant's Date Of Birth*
Date Format: MM slash DD slash YYYY
Participant's Cell Phone
If Available
Participant's Email
If Available
Participant's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
MEDICAL INFORMATION
Please list any allergies or medical conditions.

PARENT / GUARDIAN INFORMATION
(1) Parent / Guardian Name*
At least one parent or guardian is required
First Middle Last
(1) Parent / Guardian Address
If the address differs from the Participant's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
(1) Parent / Guardian Home Phone
(1) Parent / Guardian Cell Phone
(1) Parent / Guardian Work Phone
(1) Parent / Guardian Email
(2) Parent / Guardian Name
At least one parent or guardian is required
First Middle Last
(2) Parent / Guardian Address
If the address differs from the Participant's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
(2) Parent / Guardian Home Phone
(2) Parent / Guardian Cell Phone
(2) Parent / Guardian Work Phone
(2) Parent / Guardian Email

EMERGENCY CONTACT INFORMATION
(1) Emergency Contact*
First Middle Last
(1) Emergency Contact Phone*
(2) Emergency Contact
First Middle Last
(2) Emergency Contact Phone

PARENTAL CONSENT
The undersigned hereby gives permission for our (my) child ("Participant"), to attend and participate in Thalia United Methodist Church children or youth ministry activities, events, and retreates during the period of: 09/01/2016 to 09/01/2017
LIABILITY RELEASE
In consideration of Thalia United Methodist Church allowing the Participant to participate in children or youth ministry activities, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless Thalia United Methodist Church, its directors, employees, and agents (collectively herein 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 the children/youth activities. We (I) the parent(s) or legal guardian(s) of this Participant hereby grant our (my) permission for the Participant to participate fully in youth ministry activities, including trips away from the church premises. Furthermore, we (I) [and on behalf of our (my) minor Participant] hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said Church to furnish any necessary transportation (within the limitations of church insurance and the law), food and lodging for this Participant. The undersigned further hereby agree to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.
MEDICAL TREATMENT PERMISSION
We (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 diabnosis or treatment and hospital care, to be rendered to the minor under the general or special 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 hosspital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.
EARLY RETURN HOME AND TRANSPORTATION POLICY
Should it be necessary for our (my) child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transporation costs and responsibility. The undersigned also hereby gives permission for our (my) youth to ride in any vehicle driven by an approved ADULT chaperone while attending and participating in activities sponsored by Thalia United Methodist Church. My child/youth and I understand that SEAT BELTS SHALL BE WORN AT ALL TIMES during transportation.
(1) Parent / Guardian Signature*
At least one parent / guardian is required to sign
(2) Parent / Guardian Signature
Phone
This field is for validation purposes and should be left unchanged.

Step 1 of 4

PARTICIPANT INFORMATION

MEDICAL INFORMATION

PARENT / GUARDIAN INFORMATION

EMERGENCY CONTACT INFORMATION

PARENTAL CONSENT

LIABILITY RELEASE

MEDICAL TREATMENT PERMISSION

EARLY RETURN HOME AND TRANSPORTATION POLICY