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Melissa UMC

a campus of First United Methodist Church of McKinney

3851 McKinney Street

Melissa, Texas 75454

469-301-6060

In consideration of the risk of injury while participating in church sponsored activities (the “Activity”), and as consideration for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and herby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, and do hereby release and forever discharge First United Methodist Church of McKinney, operating as Melissa United Methodist Church, located at 315 N. Church Street, McKinney, Texas 75069, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned Activity, including traveling to and from an event related to this Activity.

I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITY AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH TRAVELING TO AND FROM AS WELL AS PARTICIPATING IN THIS ACTIVITY. I ASSUME ALL REALTED RISKS, BOTH KNOWN OR UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY, INDLUDING TRAVEL TO, FROM AND DURING THIS ACTIVITY. 


I ACKNOWELEDGE THAT FIRST UNITED METHODIST CHURCH OF MCKINNEY, OPERATING AS MELISSA UNITED METHODIST CHURCH AND THEIR DIRECTORS, OFFICERS, VOLUNTEERS, REPRESENTATIVES, AND AGENTS ARE NOT RESPONSIBLE FOR ERRORS, OMISSIONS, ACTS OR FAILURES TO ACT OF ANY PARTY OR ENTITY CONDUCTING A SPECIFIC EVENT OR ACTIVITY ON BEHALF OF FIRST UNITED METHODIST CHURCH OF MCKINNEY, OPERATING AS MELISSA UNITED METHODIST CHURCH. 


I ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS “WAIVER AND RELEASE” AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE FIRST UNITED METHODIST CHURCH OF MCKINNEY, OPERATING AS MELISSA UNITED METHODIST CHURCH, AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEEERS, AND REPRESENTATIVES FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST FIRST UNITED METHODIST CHURCH OF MCKINNEY, OPERATING AS MELISSA UNITED METHODIST CHURCH FOR PERSONAL INJURY OR PROPERTY DAMAGE. 


To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of First United Methodist Church of McKinney, operating as Melissa United Methodist Church, its agents, and employees.

In the event that I should require medical care or treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. I understand and agree that any expenses incurred from any medical transport, evaluation, or treatment will be solely my responsibility and not the responsibility of First United Methodist Church of McKinney, operating as Melissa United Methodist Church. I hereby authorize and appoint the pastor and staff First United Methodist Church of McKinney, operating as Melissa United Methodist Church as my agent. My agent may consent to my transportation by ambulance, examination, x-rays, diagnoses, hospitalization, anesthesia, and medication.

I Agree

In the event that any damage to equipment or facilities occurs as a result of my or my family’s willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any actions of neglect or recklessness. 

I Agree

This Agreement was entered into without duress or coercion.

In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect, so long as the clause severed does not affect the intent of the parties. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.


This waiver, release of liability and consent will remain in effect until it is revoked by notifying, in writing, the Church named above that I wish to revoke it.


I affirm that I am of the age of 18 years or older, and that I am freely signing this agreement. I certify that I have read this agreement, that I fully understand it’s content and that this release cannot be modified orally. I am aware that this is a release of liability and a contract and that I am signing it of my own free will.




Marketing release

I understand that, for all adults and minors listed on this waiver, my 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 me or my 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.

Do you agree to the statement of marketing release stated above?*
Yes
No
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Additional Emergency Contact

Emergency Contact's Name

Emergency Contact's Phone Number
Parent or Guardian's Email Address

Email*

Confirm Email*
Medical information

Primary Care Physician's name, address and telephone number *
  
Upload a picture of the FRONT of your insurance card. *
Valid file types: JPG, GIF, PNG, and PDF
  
Upload a picture of the BACK of your insurance card. *
Valid file types: JPG, GIF, PNG, and PDF
First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Medical information

List chronic or recurring illnesses

List seasonal allergies

List food allergies with reactions and treatments

List drug allergies with reactions and treatments
Is an epipen needed for any of the above allergies*
Yes
No

List all medications with dosage, time to be taken, and purpose.

When minors are traveling in a group, all medication will be secured and administered by a named adult chaperone. Minors will not be allowed keep their own medications. 

Over-the-counter medications may be administered by church staff or the adult responsible for trip medications.*
Yes
No
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Medical information

List chronic or recurring illnesses

List seasonal allergies

List food allergies with reactions and treatments

List drug allergies with reactions and treatments
Is an epipen needed for any of the above allergies*
Yes
No

List all medications with dosage, time to be taken, and purpose.

When minors are traveling in a group, all medication will be secured and administered by a named adult chaperone. Minors will not be allowed keep their own medications. 

Over-the-counter medications may be administered by church staff or the adult responsible for trip medications.*
Yes
No
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Medical information

List chronic or recurring illnesses

List seasonal allergies

List food allergies with reactions and treatments

List drug allergies with reactions and treatments
Is an epipen needed for any of the above allergies*
Yes
No

List all medications with dosage, time to be taken, and purpose.

When minors are traveling in a group, all medication will be secured and administered by a named adult chaperone. Minors will not be allowed keep their own medications. 

Over-the-counter medications may be administered by church staff or the adult responsible for trip medications.*
Yes
No
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Medical information

List chronic or recurring illnesses

List seasonal allergies

List food allergies with reactions and treatments

List drug allergies with reactions and treatments
Is an epipen needed for any of the above allergies*
Yes
No

List all medications with dosage, time to be taken, and purpose.

When minors are traveling in a group, all medication will be secured and administered by a named adult chaperone. Minors will not be allowed keep their own medications. 

Over-the-counter medications may be administered by church staff or the adult responsible for trip medications.*
Yes
No
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Medical information

List chronic or recurring illnesses

List seasonal allergies

List food allergies with reactions and treatments

List drug allergies with reactions and treatments
Is an epipen needed for any of the above allergies*
Yes
No

List all medications with dosage, time to be taken, and purpose.

When minors are traveling in a group, all medication will be secured and administered by a named adult chaperone. Minors will not be allowed keep their own medications. 

Over-the-counter medications may be administered by church staff or the adult responsible for trip medications.*
Yes
No
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Medical information

List chronic or recurring illnesses

List seasonal allergies

List food allergies with reactions and treatments

List drug allergies with reactions and treatments
Is an epipen needed for any of the above allergies*
Yes
No

List all medications with dosage, time to be taken, and purpose.

When minors are traveling in a group, all medication will be secured and administered by a named adult chaperone. Minors will not be allowed keep their own medications. 

Over-the-counter medications may be administered by church staff or the adult responsible for trip medications.*
Yes
No
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Medical information

List chronic or recurring illnesses

List seasonal allergies

List food allergies with reactions and treatments

List drug allergies with reactions and treatments
Is an epipen needed for any of the above allergies*
Yes
No

List all medications with dosage, time to be taken, and purpose.

When minors are traveling in a group, all medication will be secured and administered by a named adult chaperone. Minors will not be allowed keep their own medications. 

Over-the-counter medications may be administered by church staff or the adult responsible for trip medications.*
Yes
No
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Medical information

List chronic or recurring illnesses

List seasonal allergies

List food allergies with reactions and treatments

List drug allergies with reactions and treatments
Is an epipen needed for any of the above allergies*
Yes
No

List all medications with dosage, time to be taken, and purpose.

When minors are traveling in a group, all medication will be secured and administered by a named adult chaperone. Minors will not be allowed keep their own medications. 

Over-the-counter medications may be administered by church staff or the adult responsible for trip medications.*
Yes
No
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Medical information

List chronic or recurring illnesses

List seasonal allergies

List food allergies with reactions and treatments

List drug allergies with reactions and treatments
Is an epipen needed for any of the above allergies*
Yes
No

List all medications with dosage, time to be taken, and purpose.

When minors are traveling in a group, all medication will be secured and administered by a named adult chaperone. Minors will not be allowed keep their own medications. 

Over-the-counter medications may be administered by church staff or the adult responsible for trip medications.*
Yes
No
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Medical information

List chronic or recurring illnesses

List seasonal allergies

List food allergies with reactions and treatments

List drug allergies with reactions and treatments
Is an epipen needed for any of the above allergies*
Yes
No

List all medications with dosage, time to be taken, and purpose.

When minors are traveling in a group, all medication will be secured and administered by a named adult chaperone. Minors will not be allowed keep their own medications. 

Over-the-counter medications may be administered by church staff or the adult responsible for trip medications.*
Yes
No

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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Medical information

List chronic or recurring illnesses

List seasonal allergies

List food allergies with reactions and treatments

List drug allergies with reactions and treatments
Is an epipen needed for any of the above allergies*
Yes
No

List all medications with dosage, time to be taken, and purpose.

When minors are traveling in a group, all medication will be secured and administered by a named adult chaperone. Minors will not be allowed keep their own medications. 

Over-the-counter medications may be administered by church staff or the adult responsible for trip medications.*
Yes
No
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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