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STRAWBRIDGE UNITED METHODIST CHURCH EMERGENCY MEDICAL RELEASE  AND INFORMATION FORM

Today's Date: May 19, 2025

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*
Select Gender
First Participant's Date of Birth*
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*
Select Gender
Participant's Date of Birth*
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*
Select Gender
Participant's Date of Birth*
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*
Select Gender
Participant's Date of Birth*
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*
Select Gender
Participant's Date of Birth*
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*
Select Gender
Participant's Date of Birth*
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*
Select Gender
Participant's Date of Birth*
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*
Select Gender
Participant's Date of Birth*
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*
Select Gender
Participant's Date of Birth*
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*
Select Gender
Participant's Date of Birth*
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*
Select Gender
Parent or Guardian's Date of Birth*
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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