Medical & Permission Form
For All Youth Events, Retreats, Trips, Meetings of the College Grove United Methodist Church Tennessee Conference
Effective Dates: January 1, 2010 to January 1, 2011
Please print in ink (both sides/pages must be filled out)
Name: ___________________________________ Age: _________ Birthday: ______________
Year In School: _________ ( ) Male ( ) Female E-Mail ________________________________
Address: _______________________ City: ________________ State: _____ Zip: ______________
Phone: _______________________________ Pager/Cell: ___________________________________
Medical Insurance Company: _________________________ Policy #: _________________________
Mother's Name: ____________________ Phone/Home: ______________ Cell/Work: ________________
Father's Name: ____________________ Phone/Home: ______________ Cell/Work: ______________
Emergency Contact: __________________ Phone/Home: ______________ Cell/Work: _____________
Physician: _______________________________________________ Office Phone: ______________
Dentist: _________________________________________________ Office Phone: ______________
Medical History
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability or condition to which your child is subject and of which the staff should be made aware, and what, if any, action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken. Check the following areas of concern for this student. If necessary, add another page with details.
1. For your child's safety and our knowledge, is your student a: good swimmer fair swimmer non-swimmer
2. Does your child have allergies to: pollens, medications, food, insect bites
3. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following: asthma, epilepsy/seizure disorder, heart trouble, diabetes, frequently upset stomach, physical handicap
4. Is your child allowed to take any of these meds while on a trip? Ibuprofen, Acetaminophen/ Tylenol, Aspirin, Dramamine, Tums, Gas X, Benadryl, Imodium A-D, Hydrocortisone Cream, Neosporin, Sun block, Eye Drops, Eye Drops, Other
4. Date of last tetanus shot:
5. Does your child wear: glasses, contact lenses
6. Please list and explain any major illnesses the child experienced during the last year:
Additional Comments:
Should this child's activities be restricted for any reason? Please explain:
Activities may include, but are not limited to, cookouts, boating, water skiing, swimming, basketball, roller-skating, rollerblading, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides. NOTE: If you desire to limit your child's participation in any event, please submit your wishes in writing to the church Youth Pastor prior to that event.
_________________________________________ has my permission to attend all youth activities sponsored by the College Grove United Methodist Church, (hereinafter the "Church") from January 1, 2007 to January 1, 2008. This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child.
I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents and volunteer workers from any and all liability for any injury, loss or damage to person or property that may occur during the course of my/our child's involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.
Parent/Guardian Signature: ____________________________________ Date: _____________
This Form Must Be Notarized
STATE of TENNESSEE
County of: _________________________________________
Personally appeared before me, the undersigned, a Notary Public in and for said County and State _____________ of ________________ , ___________ , _____________________________ , to me known or provided to me on the basis of satisfactory evidence to be the person who executed the foregoing instrument as his/her free and voluntary act and deed for the purpose therein contained.
Witness my hand and official seal this (day) _______ of (month) ____________ (year) _________ .
My Commission Expires: ___________ Notary Public: ___________________________________