Palmyra United Methodist Youth Year 2017-2018
General Permission, Medical and Legal Waiver (WOW approved)
Youth Name: ______
M/F _____ Age:______Birthday:______Grade: ______
Address: ______
City:______State:______Zip: ______
Youth e-mail: ______Youth cell phone: ______
Parent/Guardian: ______
Please list all legal parents/guardians – even if they do not live with you.
Father’s e-mail:______Father’s cell phone: ______
Mother’s e-mail:______Mother’s cell phone: ______
Home phone:______Work Phone(s)______
I/We the undersigned have legal custody of the participant named above, a minor, and have
given our consent for ______to participate in the activities of the Palmyra United Methodist Youth Program.
1. I/we give permission to engage in all activities that take place in the Palmyra area, (60 miles or less from Palmyra United Methodist Church, and Quincy, Hannibal, Monroe City, Canton, Camp Jo-ota, Mark Twain Lake). Additional locations such as WOW, and others beyond 60 miles may be included in this waiver with additional parent permission.
2. I/we give permission for my/our child/youth to travel in a vehicle operated and occupied by only one adult.
3. I understand that I am responsible for arranging this young person’s transportation to and from events (even if dismissed prior to the official end of the event because of unruly behavior).
4. I give permission for photographs or video of my child to be used by the church for promotional or other purposes.
5. In case of medical emergency, I understand that attempts will be made to contact the parent or guardian. In the event that I cannot be reached, I hereby authorize and consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any licensed medical personnel on the staff of any licensed hospital. This authorization is given in advance of any specific diagnosis, treatment or hospital care required, but is given to provide authority and power to render care which is deemed advisable in the best judgment of the physician. I am responsible for payment of all fees incurred.
6. I hereby release and hold harmless and waive any claim against the Palmyra United Methodist Church, Camp Jo-Ota Association, the Mark Twain District, the Missouri Annual Conference, WOW, and their members, agencies, related organizations, representatives, officers, agents, employees, directors, and volunteers, and each of them, for any and all liability that may arise as a result of my child’s participation, except in matters of gross negligence or intentional misconduct.
Please Check any of the following that apply:
□ My child has permission to walk home alone at the end of youth events.
□ My child has permission to ride home with another parent.
□ My child has permission to taken home alone with a youth sponsor.
□ My child has permission to be taken home by another youth.
□ The following people MAY NOT pick up my child: ______
Signature ______
Date ______
Palmyra United Methodist Health Release Form Year 2017-2018
Medical Information
Full Name: ______
Alternate emergency contact (not a parent): Name______
Phone______Cell:______
Family Physician: ______Phone: ______
Family Dentist: ______Phone: ______
Preferred Hospital:______
Wear contacts? Yes/No ______Date of last tetanus______
Health Insurance information: if possible Include a copy of the health insurance card, otherwise provide the following information.
Name of company ______
Group or Plan Number: ______Member ID______
In whose name is the insurance ______
What is the phone number on the back of the card: ______
May adult leaders provide over-the-counter medications? Yes _____ No _____
If yes, are their medications that should not be given:
______
Does your child have allergies to any of the following? If yes, explain
pollens _____, medications_____, food_____,
______
______
Should this child’s activities be restricted for any reason? Please explain:
______
Special needs and restrictions (including dietary):
______
Are their other medical conditions that adult staff should be aware of?
______
______