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STRAWBRIDGE UNITED METHODIST CHURCH EMERGENCY MEDICAL RELEASE  AND INFORMATION FORM

Today's Date: December 21, 2024

In order to meet all legal requirements, I hereby grant permission for minor(s) listed below to participate in Strawbridge United Methodist Church programs.

I understand that my signature and initials convey the following:

  1. My authorization for the adult leader to obtain necessary emergency medical and/or dental treatment for said minor.

  2. I knowingly release, absolve, indemnify and hold harmless Strawbridge United Methodist Church from all claims that might result from any injury or death of any minor.

  3. Should medical and/or dental treatment be required, I agree to pay all medical, dental and/or hospital care costs either directly or through my personal health and accident insurance policy(ies).

  4. I give permission for Strawbridge United Methodist Church to include my child's photo in any form or media which may be posted on bulletin boards and/or printed in publications and advertisements for the church.

  5. I give permission for Strawbridge United Methodist Church to include my child's photo on the Church web site and other social media. (such as Website, Instagram, Internet, and Facebook)

  6. I give permission for Strawbridge United Methodist Church to provide transportation to and from all events.

This agreement will remain in effect for one year from the date above, or until revoked by me in writing.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Grade:

EMERGENCY MEDICAL INFORMATION

Physician


Name

Phone

Address

Zip

Dentist


Name

Phone

Address

Zip

Medical/Hospitalization Insurance Provider


Company Name

Address

Zip

Policy Holder Name

Policy Number

Date of last Tetanus Shot
Recommended Immunizations Current? (based on minor's age)*
Yes
No
Known allergies to: *
Penicillin
Other drugs
Food
Poisonous plants
Insect bites
Other
No known allergies

Please provide more information on allergies:

Chronic or recurring medical/health problems (i.e. asthma, bronchitis, diabetes, use of EPI Pen etc.):

Regularly used medications:

Indicate any activity restrictions:

Other comments or suggestions from the parent or guardian concerning this minor:
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Grade:

EMERGENCY MEDICAL INFORMATION

Physician


Name

Phone

Address

Zip

Dentist


Name

Phone

Address

Zip

Medical/Hospitalization Insurance Provider


Company Name

Address

Zip

Policy Holder Name

Policy Number

Date of last Tetanus Shot
Recommended Immunizations Current? (based on minor's age)*
Yes
No
Known allergies to: *
Penicillin
Other drugs
Food
Poisonous plants
Insect bites
Other
No known allergies

Please provide more information on allergies:

Chronic or recurring medical/health problems (i.e. asthma, bronchitis, diabetes, use of EPI Pen etc.):

Regularly used medications:

Indicate any activity restrictions:

Other comments or suggestions from the parent or guardian concerning this minor:
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Grade:

EMERGENCY MEDICAL INFORMATION

Physician


Name

Phone

Address

Zip

Dentist


Name

Phone

Address

Zip

Medical/Hospitalization Insurance Provider


Company Name

Address

Zip

Policy Holder Name

Policy Number

Date of last Tetanus Shot
Recommended Immunizations Current? (based on minor's age)*
Yes
No
Known allergies to: *
Penicillin
Other drugs
Food
Poisonous plants
Insect bites
Other
No known allergies

Please provide more information on allergies:

Chronic or recurring medical/health problems (i.e. asthma, bronchitis, diabetes, use of EPI Pen etc.):

Regularly used medications:

Indicate any activity restrictions:

Other comments or suggestions from the parent or guardian concerning this minor:
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Grade:

EMERGENCY MEDICAL INFORMATION

Physician


Name

Phone

Address

Zip

Dentist


Name

Phone

Address

Zip

Medical/Hospitalization Insurance Provider


Company Name

Address

Zip

Policy Holder Name

Policy Number

Date of last Tetanus Shot
Recommended Immunizations Current? (based on minor's age)*
Yes
No
Known allergies to: *
Penicillin
Other drugs
Food
Poisonous plants
Insect bites
Other
No known allergies

Please provide more information on allergies:

Chronic or recurring medical/health problems (i.e. asthma, bronchitis, diabetes, use of EPI Pen etc.):

Regularly used medications:

Indicate any activity restrictions:

Other comments or suggestions from the parent or guardian concerning this minor:
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Grade:

EMERGENCY MEDICAL INFORMATION

Physician


Name

Phone

Address

Zip

Dentist


Name

Phone

Address

Zip

Medical/Hospitalization Insurance Provider


Company Name

Address

Zip

Policy Holder Name

Policy Number

Date of last Tetanus Shot
Recommended Immunizations Current? (based on minor's age)*
Yes
No
Known allergies to: *
Penicillin
Other drugs
Food
Poisonous plants
Insect bites
Other
No known allergies

Please provide more information on allergies:

Chronic or recurring medical/health problems (i.e. asthma, bronchitis, diabetes, use of EPI Pen etc.):

Regularly used medications:

Indicate any activity restrictions:

Other comments or suggestions from the parent or guardian concerning this minor:
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Grade:

EMERGENCY MEDICAL INFORMATION

Physician


Name

Phone

Address

Zip

Dentist


Name

Phone

Address

Zip

Medical/Hospitalization Insurance Provider


Company Name

Address

Zip

Policy Holder Name

Policy Number

Date of last Tetanus Shot
Recommended Immunizations Current? (based on minor's age)*
Yes
No
Known allergies to: *
Penicillin
Other drugs
Food
Poisonous plants
Insect bites
Other
No known allergies

Please provide more information on allergies:

Chronic or recurring medical/health problems (i.e. asthma, bronchitis, diabetes, use of EPI Pen etc.):

Regularly used medications:

Indicate any activity restrictions:

Other comments or suggestions from the parent or guardian concerning this minor:
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Grade:

EMERGENCY MEDICAL INFORMATION

Physician


Name

Phone

Address

Zip

Dentist


Name

Phone

Address

Zip

Medical/Hospitalization Insurance Provider


Company Name

Address

Zip

Policy Holder Name

Policy Number

Date of last Tetanus Shot
Recommended Immunizations Current? (based on minor's age)*
Yes
No
Known allergies to: *
Penicillin
Other drugs
Food
Poisonous plants
Insect bites
Other
No known allergies

Please provide more information on allergies:

Chronic or recurring medical/health problems (i.e. asthma, bronchitis, diabetes, use of EPI Pen etc.):

Regularly used medications:

Indicate any activity restrictions:

Other comments or suggestions from the parent or guardian concerning this minor:
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Grade:

EMERGENCY MEDICAL INFORMATION

Physician


Name

Phone

Address

Zip

Dentist


Name

Phone

Address

Zip

Medical/Hospitalization Insurance Provider


Company Name

Address

Zip

Policy Holder Name

Policy Number

Date of last Tetanus Shot
Recommended Immunizations Current? (based on minor's age)*
Yes
No
Known allergies to: *
Penicillin
Other drugs
Food
Poisonous plants
Insect bites
Other
No known allergies

Please provide more information on allergies:

Chronic or recurring medical/health problems (i.e. asthma, bronchitis, diabetes, use of EPI Pen etc.):

Regularly used medications:

Indicate any activity restrictions:

Other comments or suggestions from the parent or guardian concerning this minor:
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Grade:

EMERGENCY MEDICAL INFORMATION

Physician


Name

Phone

Address

Zip

Dentist


Name

Phone

Address

Zip

Medical/Hospitalization Insurance Provider


Company Name

Address

Zip

Policy Holder Name

Policy Number

Date of last Tetanus Shot
Recommended Immunizations Current? (based on minor's age)*
Yes
No
Known allergies to: *
Penicillin
Other drugs
Food
Poisonous plants
Insect bites
Other
No known allergies

Please provide more information on allergies:

Chronic or recurring medical/health problems (i.e. asthma, bronchitis, diabetes, use of EPI Pen etc.):

Regularly used medications:

Indicate any activity restrictions:

Other comments or suggestions from the parent or guardian concerning this minor:
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Grade:

EMERGENCY MEDICAL INFORMATION

Physician


Name

Phone

Address

Zip

Dentist


Name

Phone

Address

Zip

Medical/Hospitalization Insurance Provider


Company Name

Address

Zip

Policy Holder Name

Policy Number

Date of last Tetanus Shot
Recommended Immunizations Current? (based on minor's age)*
Yes
No
Known allergies to: *
Penicillin
Other drugs
Food
Poisonous plants
Insect bites
Other
No known allergies

Please provide more information on allergies:

Chronic or recurring medical/health problems (i.e. asthma, bronchitis, diabetes, use of EPI Pen etc.):

Regularly used medications:

Indicate any activity restrictions:

Other comments or suggestions from the parent or guardian concerning this minor:
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

In cases where parent/guardian is unavailable, name of friends/relatives to be contacted in the event of an emergency:


Name: *

Relationship: *

Phone: *

Name:

Relationship:

Phone:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Grade:

EMERGENCY MEDICAL INFORMATION

Physician


Name

Phone

Address

Zip

Dentist


Name

Phone

Address

Zip

Medical/Hospitalization Insurance Provider


Company Name

Address

Zip

Policy Holder Name

Policy Number

Date of last Tetanus Shot
Recommended Immunizations Current? (based on minor's age)*
Yes
No
Known allergies to: *
Penicillin
Other drugs
Food
Poisonous plants
Insect bites
Other
No known allergies

Please provide more information on allergies:

Chronic or recurring medical/health problems (i.e. asthma, bronchitis, diabetes, use of EPI Pen etc.):

Regularly used medications:

Indicate any activity restrictions:

Other comments or suggestions from the parent or guardian concerning this minor:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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