Decatur First United Methodist Church

Activity Consent and Release

The Decatur First United Methodist Church takes every precaution to make sure your child is provided a safe environment during activities and trips. Please carefully read, completeand sign this form:

Youth Name
Parent/ Guardian Name
Street Address
City, St Zip
Primary Phone
Secondary Phone
Parent Email
Student DOB/ Grade
Insurance Name
Group ID/ Policy #
Allergies
Medications

The youth listed above has permission to participate in an off-site outreach program of Vacation Bible School (June 12 - 16) through Decatur First United Methodist Church. Children will depart from the main church campus at 300 E. Ponce de Leon Ave., Decatur GA 30030,and travel (via walking or church bus) to: Children Read, 2963 N. Druid Hills Rd. Atlanta GA 30329; Holy Trinity Church, 515 E. Ponce de Leon Ave., Decatur GA 30030; Action Ministries Feed the Hungry Warehouse, 2160 Hills Ave., Bldg. 2, Suite F, Atlanta GA 30318; Global Growers (Decatur’s Kitchen Garden) on the United Methodist Children’s Home Campus, 500 S. Columbia Dr., Decatur GA 30030; and Decatur Cemetery, 229 Bell St., Decatur GA 30030.Activities take place between8:45 am – 12:15 pm daily.

I understand that participation in the activity involves a certain degree of risk. I have carefully considered the risk involved and have given consent for myself or my child to participate in the activity. I understand that participation in the activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release Decatur First United Methodist Church, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation including transportation to and from activity. I agree that my child’s likeness may be used by Decatur First United Methodist Church for promotion of Youth Ministry and Church events.

In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.

I understand that Decatur First United Methodist Church, Inc. does not carry accident or medical insurance on participants or volunteers. I agree that my insurance company will be used for such treatment expenses not covered by my insurance. I understand that if I do not have medical insurance coverage that I am responsible for the payment of any and all medical bills.

Participant Signature ______Date ______

Parent/Guardian Name ______

Parent/ Guardian Signature ______Date______

Emergency Contact 1 (in addition to name above): / Emergency Contact #2 (in addition to name above):
Name: / Name:
Relationship: / Relationship:
Phone 1: / Phone 1:
Phone 2: / Phone 2:

Please list any special pick up instructions or other adults authorized to pick up your child that we should be aware of: ______

______

Please list any additional health information (epi-pens, special instructions that we should be aware of):

______

______

______

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