Youth Group2014-2015Permission/Waiver Form

(Grades7-12only)

YouthInformation Youth #1 Youth#2 Youth#3
FirstNameLastName
DateofBirth
Listanymedicalproblems,
allergies,etc.
YouthCellPhone
YouthEmail
FamilyInformation
ParentName
Street Address
City,State,Zip
FamilyHomePhone
ParentCellPhone
PhysicianName
Telephone#
InsuranceCo.
Telephone
Policy#
EmergencyContactName
Telephone#

Iwouldlikemoreinformationaboutbeinga YouthMinistryVolunteerOVER

Permission for Publicity

Onoccasion,Newark United Methodist Churchtakesphotographs ormakes anaudio orvideotaperecording ofchildrenand/oradultsinvolved in church/youthactivities. Iconsenttotheuseofanysuch audio or visualrecord ofthe childnamedabove(or me,ifI amparticipating) to beused,distributed, ordisplayed as agentsofthechurchseefit.

I give permissionforpublicity: I donotgive permissionfor publicity:

Release of Liability

Bysigning thiswaiver form, Igrantpermissionfor the childnamed above(or me, ifIamaparticipant)toparticipateinandengage inthe2012-2013youthgroupeventsofNewark United MethodistChurch. Mychild and I arephysicallyand mentally able toparticipate intheseactivities, unlessI havealreadydiscussed it withoneoftheleaders.Iacknowledgethatthere are certain risks involved in said activities and have discussedthemwith mychild ifnecessary.

I releaseNewark United Methodist Church, itsaffiliates,volunteers,andemployeesof allresponsibilitiesfor anyinjuries, to bodyor property,which mayoccur tomychild duringthe courseoftheseactivities. Intheeventof an emergencyin whichneither I or thealternatecontactcan bereached,I authorize the adultleaders tomakemedicaldecisionsformychildandtoadministerfirst aid ifdeemednecessary.

Ifurther agreetoindemnifyandholdharmlessNewark United Methodist Churchanditsaffiliates,volunteers,andemployeesof anyand all claimsarisingfrom mychild’s (or my)participation inactivities or as aresultofinjuryor illness of mychild(or me)duringsuchactivities.

I representthatI amtheparticipant,or parent/guardian of,who is under18 yearsofage.I have read thePermission/Waiver Formandam fullyawareof the contentsthereof.I give permissionfor thechildnamedabove(or me)tofullyparticipate in theactivitiesofNewark United Methodist Church.

SignatureofParticipant or Parent/Guardian

Date

Newark United MethodistChurch, 69E. Main Street,Newark, DE19711

phone:(302) 368-8774website: newark-umc.org fax:(302) 368-8705