State Street United Methodist Church

Permission & Medical Release Form

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I give permission for _________________________________________________ (name of youth) to travel in the State Street UMC church van to _________________________________________(name & place of event) on ___________________ (date).

 I, ________________________________ (Parent or Guardian's Name) hereby give permission for any and all medical attention to be administered to my child __________________________________ (Childs Name) in the event of accident, injury, sickness, ect. Under the direction of the chaperone's of State Street United Methodist Church, until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment.

Insurance Company:______________________________________________________

Policy Number: __________________________________________________________

Physician :______________________________________________________________

Address: _______________________________________________________________

Phone:__________________________________________________________________

Medical History

Known Allergies:_________________________________________________________

Current Medications:_____________________________________________________

Contact Information

Mom's email _____________________________

Dad's email _______________________________

Youth's email ________________________________

Emergency Contact Information

Home phone _________________

Mom's cell phone ______________

Dad's cell phone __________________

Youth's cell phone _________________________

 

Signature of Parent or Guardian: _______________________________Date___________