YOUTH GROUP PARTICIPATION CONSENT FORM
Sparta United Methodist Church - Youth Ministry: 2017
71 Sparta Ave. Sparta, NJ 07871 - (973) 729-7773
Youth’s Name: ______Date: ______
Age: ______Birth Date: ______Grade in School: ______
Address: ______
Youth’s Preferred Method of Contact: ______
Mother’s Name: ______Phone: ______
Father’s Name: ______Phone: ______
Preferred Email Address for Contact: ______
Emergency Contact if above cannot be reached:
Name: ______Phone: ______
Relationship: ______
Please list any known medical information: ______
______
Insurance Company: ______Policy#: ______
Primary Care Physician: ______Phone: ______
Liability Release: The undersigned does hereby give permission, as noted by initials, below:
For our (my) child, ______, to attend and participate in activities sponsored by Sparta UMC for the year 2017. For our (my) child to ride in any vehicle designated by assigned adult in whose care the minor has been entrusted while attending/participating in activities sponsored by Sparta UMC. Further, I am aware that Sparta UMC employs a Safe Sanctuary Policy in its supervision of Youth and I may view the policy, if requested, via the church office. In the event of any unforeseen accident, injury, disability, to myself, my child’s person or property, I will hold harmless and free of liability: Sparta UMC, Sparta UMC Youth Leaders, both individually and as a group.
Initials: ______
Photo Release: I understand that photos may be taken during Sparta UMC Youth events/activities and may include event participants. My initials below indicate my permission that photographs, films, or recordings taken as part of these events, may be used in print or electronic media (i.e. Facebook, Instagram) created by Sparta UMC and/or the Greater New Jersey Conference of the United Methodist Church.
Initials: ______
Medical Release: I authorize an adult leader in whose care my child has been entrusted, to provide first aid/emergency care to my son/daughter in accord with their judgment, treatment which may include administration of over-the-counter (non-prescription) and/or prescribed medications (for my child) to my child. If it is deemed necessary, I give consent to any x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to my child under the general or special supervision of, 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 hospital, whether such diagnosis or treatment is rendered at said physician’s office or at said hospital.
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 pursuant to this authorization. If necessary for our (my) child to return home from an event due to medical reasons or otherwise, the undersigned shall assume all transportation costs. I UNDERSTAND I AM GIVING UP IMPORTANT LEGAL RIGHTS BY SIGNING THIS DOCUMENT.
MY COVENANT: We agree to give our best efforts to this ministry, to respect other participants and their property at all times, and treat others as we wish to be treated.
Student’s Signature: ______Date: ______
Mother’s Signature: ______Date: ______
Father’s signature: ______Date: ______