Medical release - new 2012

First United Methodist Church of Birmingham Medical Release Form
YOUTH INFORMATION
Name: ___________________________________________________Date of Birth:____________________ Grade: _________________ Address: __________________________________________________Home Phone:__________________________________________ City, State, Zip: ________________________________________________________________________________________________ Parent(s) Name(s):_______________________________________________________________________________________________ Parent(s) cell phone (s) __________________________________________Student cell phone:__________________________________ INSURANCE INFORMATION
Is participant covered by a medical insurance policy? Yes ____________ No____________ Name of Policy Holder: _________________________________Relationship to Participant:_____________________________________ Insurance company: __________________________________Policy number/Group number:___________________________________ Family Doctor: _______________________________________Doctor Phone:_______________________________________________ Date of last tetanus shot____________________________ ALLERGIES AND MEDICAL CONDITIONS Please attach additional information if necessary.
List all current prescription and non-prescription medications: PERMISSION TO DISPENSE NON-PRESCRIPTION MEDICATIONS
There are often times when over-the-counter medications are requested by youth or are necessary to relieve minor discomfort. Please
indicate below which medications you authorize to be dispensed by a staff member or a designated adult sponsor. Please note that
medications will not be distributed without parent/guardian permission, even if it means your youth remains uncomfortable.
YES __________NO__________ Acetaminophen for pain relief (e.g. Tylenol)
YES __________NO __________Ibuprofen for pain relief (e.g. Advil, Aleve) YES __________NO __________Digestive pain relief (e.g. Pepto-Bismol, Antacid, Imodium, Tums, anti-diarrhea) YES __________NO __________Cold, allergy, and sinus relief (e.g. Claritin, Benadryl) YES __________NO __________ Motion sickness relief (e.g. Dramamine) PARENT COVENANT
Permission and Medical Release: I, the parent or guardian, grant my permission for him/her to participate fully in all youth
activities, events, and trips sponsored by First United Methodist Church of Birmingham. In the event treatment is called
for in which a physician (or hospital personnel) is needed, I authorize adult leaders, volunteer or paid, to give such consent for all
necessary medical treatment if we cannot be reached or if because of an emergency. Should medical help be needed, I agree to pay
either directly and/or through my own health insurance policy all medical or hospital costs and to be solely responsible for said
treatment and the cost thereof. I will keep my contact information up to date so I may be contacted as needed.
Waiver of Liability: I, the parent or guardian, in consideration of my youth being allowed to participate in all youth activities, events, and
trips, being the undersigned, intending to be legally bound, hereby waive and release all rights and claims for
damages, for injury, accident, or liability of any kind which I might have against the First United Methodist Church of Birmingham, church
staff, volunteer leaders and other participants. I acknowledge that my youth will participate at his/her own risk.
Photo Disclaimer: I, the parent or guardian, understand my youth will be involved in public performance and give permission for my
youth’s photo or video to be placed on the website, in newspapers, publications, or in other promotional materials.
Supervisory Responsibility & early dismissal: I, the parent or guardian, understand that staff and volunteer leaders of First United
Methodist Church of Birmingham, are responsible for my youth only while they voluntarily remain with the group. If my youth were
to leave the group, I understand the First United Methodist Church of Birmingham, church staff, or volunteer leaders are not responsible.
I have discussed this with my youth, and my youth is aware of our expectations for behavior while on the trip. I understand my youth
may be sent home early at my expense with no refund if they do not follow the “participant covenant.”
PARENT/GUARDIAN SIGNATURE:______________________________________________________*DATE:_________________
On this ______________ ___day of ____________, the above signed personally appeared before me. Notary Signature:_____________________________________________

Source: http://www.fumcbirmingham.org/wp-content/uploads/2012/08/Medical-Release-New-2012.pdf