Loading...

First United Methodist Church
315 N. Church Street
McKinney, TX 75069

MEDICAL RELEASE FORM

 

 

First United Methodist Church of McKinney

 

PARENTAL PERMISSION, PERSONAL LIABILITY & MEDICAL RELEASE

 

Liability Release --The undersigned, being the parent, guardian, or managing conservator of (minor name(s)):

Such child/youth being under eighteen (18) years of age, does give permission for such child/youth to participate in activities at, or sponsored by, the church named above (hereafter “the Church”). Being the legal and acting guardian of the child/youth, and acting for myself and the on behalf of my child/youth, I release and hold harmless the Church and its respective staff, employees, volunteers, agents and representatives of any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the child/youth and/or the undersigned resulting from any cause whatsoever occurring to the child/youth and/or myself at any time while attending any activity, including travel to and from any activity, excepting only such injury or damage resulting from willful acts of these individuals.

 

Medical Release— Being the natural parent (or legal guardian) of the above named minor , I do hereby make, constitute and appoint First United Methodist Church of McKinney as my true and lawful, attorney in-fact for the limited purpose of consenting to emergency medical treatment for the above named minor, which consent shall not terminate on my physical or mental disability subsequent to the date of execution hereof.  

I voluntarily give permission for the Church to administer and/or obtain routine or emergency medical treatment for my child/youth as deemed necessary under the circumstances.

Any further treatment will require parental or guardian consultation and consent. I agree to indemnify and hold harmless the Church and their respective staff, employees, volunteers, agents and representatives for any and all claims, demands, actions, rights of action, and/or judgments by or on behalf of my child/youth and/or me arising from or on account of these procedures and/or treatment rendered in good faith and according to accepted medical standards. I also agree that I will be responsible for any financial debt incurred by the rendering of emergency medical treatment.

 

Transportation Release— I give permission for my child/youth to be transported either by Church-provided transportation, commercial bus or by Church leaders’ private vehicles for field trips, mission trips, Vacation Bible School, and/or other activities. If I do not want my child/youth to use this transportation, I will take sole responsibility to provide transportation or to see that my child/youth do not attend the activity.

 

Marketing Release— I understand that my child/youth picture, art, written work, voice, verbal statements or portraits (video or still) may appear in publicity or publications, videos or on the Church website. These pictures and items will not personally identify the child/youth unless I specifically provide permission to do so. No monetary consideration will be paid. I understand that these pictures and items may be used by the Church in perpetuity, and that this agreement is binding upon heirs and/or future representatives.

 

I, on my own behalf and on behalf of my child/youth, hereby warrant that I have read this Release in its entirety and fully understand its contents, and am aware that this form releases the Church from liability, and have signed this form of my own free will. I understand that this authorization shall be effective continuously from the date hereof until canceled by written notice to the Church. I agree to update this information in writing as the need arises.

 

September 29, 2022


First Participant's Name

First Name*

Middle Name

Last Name*

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

Participant does not have any medical problems or special physical conditions to my knowledge, other than the following: *
Permission is given for the church to administer over-the-counter medicine as needed.*
Yes
No

If yes, what over-the-counter medications is the church allowed to give your child/youth?
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Participant does not have any medical problems or special physical conditions to my knowledge, other than the following: *
Permission is given for the church to administer over-the-counter medicine as needed.*
Yes
No

If yes, what over-the-counter medications is the church allowed to give your child/youth?
Second Participant's Signature*
Third Participant's Name

First Name*

Middle Name

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

Participant does not have any medical problems or special physical conditions to my knowledge, other than the following: *
Permission is given for the church to administer over-the-counter medicine as needed.*
Yes
No

If yes, what over-the-counter medications is the church allowed to give your child/youth?
Third Participant's Signature*
Fourth Participant's Name

First Name*

Middle Name

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

Participant does not have any medical problems or special physical conditions to my knowledge, other than the following: *
Permission is given for the church to administer over-the-counter medicine as needed.*
Yes
No

If yes, what over-the-counter medications is the church allowed to give your child/youth?
Fourth Participant's Signature*
Fifth Participant's Name

First Name*

Middle Name

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

Participant does not have any medical problems or special physical conditions to my knowledge, other than the following: *
Permission is given for the church to administer over-the-counter medicine as needed.*
Yes
No

If yes, what over-the-counter medications is the church allowed to give your child/youth?
Fifth Participant's Signature*
Sixth Participant's Name

First Name*

Middle Name

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

Participant does not have any medical problems or special physical conditions to my knowledge, other than the following: *
Permission is given for the church to administer over-the-counter medicine as needed.*
Yes
No

If yes, what over-the-counter medications is the church allowed to give your child/youth?
Sixth Participant's Signature*
Seventh Participant's Name

First Name*

Middle Name

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

Participant does not have any medical problems or special physical conditions to my knowledge, other than the following: *
Permission is given for the church to administer over-the-counter medicine as needed.*
Yes
No

If yes, what over-the-counter medications is the church allowed to give your child/youth?
Seventh Participant's Signature*
Eighth Participant's Name

First Name*

Middle Name

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

Participant does not have any medical problems or special physical conditions to my knowledge, other than the following: *
Permission is given for the church to administer over-the-counter medicine as needed.*
Yes
No

If yes, what over-the-counter medications is the church allowed to give your child/youth?
Eighth Participant's Signature*
Ninth Participant's Name

First Name*

Middle Name

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

Participant does not have any medical problems or special physical conditions to my knowledge, other than the following: *
Permission is given for the church to administer over-the-counter medicine as needed.*
Yes
No

If yes, what over-the-counter medications is the church allowed to give your child/youth?
Ninth Participant's Signature*
Tenth Participant's Name

First Name*

Middle Name

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

Participant does not have any medical problems or special physical conditions to my knowledge, other than the following: *
Permission is given for the church to administer over-the-counter medicine as needed.*
Yes
No

If yes, what over-the-counter medications is the church allowed to give your child/youth?
Tenth Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Additional Emergency Contact

Emergency Contact Name:

Emergency Contact Number:
Insurance Provider & Policy Number

Insurance Provider *

Policy Number *

Member ID

Group Number
Family Doctor Information

Family Doctor: Name *

Office 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

Participant does not have any medical problems or special physical conditions to my knowledge, other than the following: *
Permission is given for the church to administer over-the-counter medicine as needed.*
Yes
No

If yes, what over-the-counter medications is the church allowed to give your child/youth?
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!