State Street United Methodist Church
Safe Sanctuaries Policy - Child/Youth Program Participation
Personal Information Form
This form must be filled out and submitted annually. This form is in effect from September 1, 2006 through August 31, 2007
This form was submitted or updated on ____________________________________________ (Date)
Full name of child ___________________________________________Nickname _______________________
Date of Birth ___________________ Grade _____ School Attends ___________________________________
Parents' or legal guardians' names ______________________________________________________________
Address___________________________________________________________________________________
Home Phone _______________________________________________________________________________
Place of Employment (Father)__________________________________________________________________
Work Phone (Father)_______________________________Cell (Father)________________________________
Place of Employment (Mother)_________________________________________________________________
Work Phone (Mother)_____________________________ Cell (Mother)_______________________________
Email (Father) _______________________________Email (Mother) _______________________________
Email (Child or Youth) _______________________________
Please provide the information for a second parent or guardian if that information differs from any of the above.
Name_____________________________________________________________________________________
Address ___________________________________________________________________________________
Home Phone ________________________________ Work Phone ____________________________________
Cell Phone_______________________________________________
Medical Information:
Name of child's physician ____________________________________________________________________
Physician phone number______________________________________________________________________
Insurance information________________________________________________________________________
Allergies? ____________________________________________Please describe.
Does your child take medication? _____Yes _____ No If yes, please describe.
Additional Information
Name and phone number of additional contact person in case of emergency. (this should be someone who is familiar with the family members and who would be likely to know where a parent or guardian can be located.)
Name ________________________________________________
Phone _____________________
Parent/Guardian Permission
I hereby give permission for photographs or videos taken of my child to be used for ministry publicity, either printed or electronic. I understand that my child's name will not be disclosed.
Yes _______ No _______
I hereby give permission to adult personnel designated by State Street United Methodist Church to obtain emergency medical services including transportation to the hospital emergency room for my child if immediate medical care is necessary.
Yes ______ No ______
I hereby give permission for State Street UMC volunteer or staff to administer first aid treatment to my child in any situation encountered while my child is participating in a program with State Street United Methodist Church.
Yes _____ No _____
I hereby give permission for my child to travel by church van and to cross state lines to participate in activities with State Street United Methodist Church.
Yes _____ No _____
Parent or guardian signature _____________________________________________
Date ____________________________
Relationship to child ______________________________________________________
All information will be assumed to be current. It is the responsibility of the parent or guardian to update this information as needed!
You may email this form to Jaymie Derden.