Grace United Methodist Church
9411 N. County Rd. 25-A Piqua, OH 45356
Phone: 937.773.8232 E-mail:
Name ______
Birth date ______/______/______
School Grade ______Name of School ______
Parent(s)/Guardian(s) Name ______
Home Phone ______Cell Phone ______
Home Address ______
City ______State ______ZIP ______
In case of emergency, notify:
Name ______
Home Phone ______Cell Phone ______
Doctor ______City ______Phone ______
Health History:
Allergies:
(Mark YES or NO) Insect Stings ______Medications ______if yes what type ______
Other Conditions:
Heart ______Stomach ______Diabetes ______Epilepsy ______
Asthma ______Other ______
If you checked any of the above, please give more information such as treatments, signs and symptoms, etc.
______
______
Can he or she swim? ______Yes ______No
Any Swimming Restrictions ______Yes ______No
If yes please explain:______
Statement of Release:
All youth sponsored activities conducted by Grace United Methodist Churchare carefully planned by leaders who are all mature adults. However, even with proper planning and precaution, unpredicted events can occur. By signing this form, the parent(s), guardian(s), or participant agrees to assume and accept all risks and dangers that may come up in youth-related activities. The parent(s) or guardian(s) agrees not to hold Grace United Methodist Church or any of its employees or volunteers liable for any damages, losses, sickness, or injuries to the above named person. The parent(s), guardian(s) or participantalso understands that their signature is both for medical and liability release. Further, Authorization and permission is hereby given to Grace United Methodist Church to furnish any necessary transportation, food, and lodging, for the participant(s), as deemed necessary or desirable by Grace United Methodist Church, staff or representatives. By signing this release you are also giving consent and authorization for emergency transportation and any medical treatment deemed necessary by medical staff. Should it be necessary for the student(s) participant(s) to return home due to any medical reason, disciplinary action or otherwise, I(we) hereby assume responsibility and shall pay for all transportation cost. In addition, I understand that my child or the participant may be photographed or recorded on video during the course of youth ministry events. By signing below I provide consent for their or my image to be used in print, electronic, or video form for the promotional purpose of future retreats and youth group activities. The form will be valid thru December 31, 2016, unless terminated in writing.
Signatures:
______
FatherDate
______
Mother Date
______
Legal GuardianDate
Participant Only
I have read the foregoing and understand the rules of conduct for participants and will abide by them as well as the direction of the leadership of all activities and events.
______
ParticipantDate