Name:*
Gender: Male Female
Birthday: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Cellular Number:( ) -
Email Address:
School:
Grade:
Church that you attend:
Boy Scout Troop 990
Camping
Cooking
Music
Sports
Other activities that you enjoy:
Mom's Name:
Mom's Cellular Number:( ) -
Mom's email address:
Dad's Name:
Dad's Cellular Phone:( ) -
Dad's email address:
Who do you live with? Live with Mom Live with Dad Live with Both
Emergency Contact #1:
Emergency Contact #1 Phone:( ) -
Emergency Contact #2:
Emergency Contact #2 Phone:( ) -
General Health Information
List Youth's Environmental Allergies (example, poison ivy; N/A if none):
List of Youth's Food Allergies (example, dairy; N/A if none):
If the Youth has food allergies, do they carry an EpiPen? Yes No N/A
Does the Youth have any medical or health problems, and has the Youth child had any chronic or recurring illness or illnesses, which would have an effect on the Youth's participation in this Activity? Yes No N/A
If yes, please describe (example, exercise induced asthma):
Date of Youth's last tetanus shot: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
Are there any activities that should be restricted for the student? Yes No
If yes, please list:
Is Youth on any medications? Yes No
Will Youth bring this medication to Weekly Youth Events? Yes No N/A
Will Youth bring this medication to Overnight Youth Events? Yes No N/A
Medical Care Providers
Youth's Primary Care Doctor:
Primary Care Doctor's Phone:( ) -
Youth's Dentist:
Dentist's Phone:( ) -
Medical/Hospital Insurance
Is there medical or hospitalization insurance which provides benefits for this Youth? Yes No
If yes, Name of Insurance Company:
Insurance Company Phone:( ) -
Policy Number:
Name of Policy Holder:
Medical Consent & Release:
I understand that FCUMC Youth Ministry carries medical and hospitalization insurance coverage which, consistent with the exclusions, limitations, and terms thereof, may provide benefits over and above any personal medical and hospitalization coverages available to my family. I understand that any personal medical and hospitalization insurance available to my family will provide primary coverage and the ministry's medical and hospital coverage (subject to the exclusions, limitations and provisions in the ministry's policy) may provide secondary or excess coverage. I agree to apply first for benefits from the personal hospitalization and medical coverage available to my family, if any, before applying for benefits that may be available from the ministry's medical and hospitalization coverage.
I further understand that, in the event my child requires medical or dental treatment while engaged in the Activity, reasonable efforts will be made to contact me; however, if I cannot be reached, I hereby consent and give permission to the ministry's sponsor or any adult counselor acting on behalf of the ministry with respect to the Activity, as agent for me, to consent to any X -ray examination; examination; injections; anesthesia; medial, dental, or surgical diagnosis and treatment; and hospital care and treatment advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all of my child’s medical allergies, medications being taken, medical problems, and other pertinent information. My child has permission to participate in all prescribed activities except as noted by me.
Participation Consent & Release:
In consideration of the benefits of participation in the activities of Faith Community United Methodist Church, Inc. (“Church”), an Ohio non-profit corporation, I/we, for my/our minor child and/or myself/ourselves, the heirs, personal representatives or assigns of my/our minor child and/or myself/ourselves, consent to my/our child’s participation in Church Activities and further waive all claims or causes of action against Church, its agents, Board of Servant Leaders, trustees, employees and volunteers (collectively referred to as the “Church Group”); arising out of my/our minor child’s and/or my/our participation in Church Activities and hereby release, hold harmless and discharge the Church Group from any and all liability, claims, demands, actions and causes of action whatsoever, including reasonable attorney fees, arising out of or related to any loss, damage or injury (whether direct, indirect, consequential or otherwise), including death, that my/our minor child and/or I/we might sustain or that any of my/our minor child’s and/or my/our property might sustain while participating in any Church Activities.
Assumption of Risks:
Knowing, understanding, and fully appreciating all possible risks, I/we hereby expressly, voluntarily and willingly assume all risks and dangers associated with my/our minor child’s and/or my/our participation in Church Activities. I/we understand and acknowledge that Church Activities could result in injury and I/we agree that participation in all Church Activities shall be at my/our minor child’s and/or my/our sole risk.
Acknowledgement of Understanding:
I/we have read this Consent, Waiver, and Release Agreement and understand the terms used in it and their legal significance. This Consent, Waiver, and Release Agreement is freely and voluntarily given with the understanding that right to legal recourse against the Church Group is knowingly given up in return for allowing my/our minor child’s and/or my/our participation in Church Activities. I/we agree that this Consent, Waiver, and Release Agreement shall remain in effect and apply each time my/our minor child and/or I/we participate in any Church Activities.
Photo Release:
From time to time we take photos or film videos during children’s and youth activities at Faith Community United Methodist Church. We would like your permission to use these photos or videos for bulletin boards, fliers, newsletters or online including our website, e-newsletters, and social media. We will not reference your child by name or provide any specific information regarding your child. The pictures or videos will only be used to show the many ways children and youth have fun while participating in preschool and church activities at Faith Community United Methodist Church.
By typing my/our name and the date, below, I/we acknowledge and accept all terms and conditions of this Consent, Waiver, and Release Agreement. If I/we am/are signing this Consent, Waiver, and Release Agreement on behalf of a minor, I/we certify that all representations are true and that I/we am/are the minor’s legal guardian(s) or custodial parent(s) with full authority to bind the minor and myself/ourselves to the terms and conditions of this Consent, Waiver, and Release Agreement.
Student
Student Name:*
Date* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
Parent(s)
Date January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
Photo Preference
YES. I grant permissions to use photos or videos of my child on Faith Community United Methodist Church bulletin boards, fliers newsletters, website, e-newsletters and social media.
NO. Please do NOT use any photos or videos of my child.
