Microsoft word - fumcmedical.doc

Youth’s Name:_____________________________________________________________________
Youth e-mail:_______________________________ Parent’s e-mail_______________________________
DOB:__________________ Age:__________Grade:_____________ T-Shirt size_______________
Address:_____________________________ Zip___________ Home phone number:_____________
Work Phone:__________________________________ Alt#_____________________________
Mother/Guardian’s Name:____________________________DOB:_______/__________/_________
Work Phone:_____________________________________Alt#_______________________________
Close Relative or Friend:__________________Hm Phone:_____________Wk Phone:______________
Any known allergies requiring special attention: ____________________________________________
Medical history:______________________________________________________________________
Date of last Tetanus shot:_______________________________________________________________
Current medications, dosage & use:_______________________________________________________
Physician:______________________________________ Phone: ___________________________
Dentist:________________________________________ Phone:___________________________
Health Insurance Group:___________________________ Group#_____________________________
Insurance Company Address:_______________________________Phone#_______________________
DOB of Primary Card Holder:____/____ /_____ (hospital requirement for medical attention)

I hereby give consent to any of the First UMC Austin staff and/or volunteer staff to seek emergency medical
treatment for my child(ren) named above in the event of an emergency and in my absence While understanding
that all reasonable safety precautions will be observed, I understand the possibility of unforeseen hazards and the
inherent possibility of risk. I voluntarily agree not to hold legally liable First UMC Austin, any of its employees,
volunteers, or other representatives associated with providing or arranging for emergency medical treatment for
my child(ren).”
I herby grant permission for First United Methodist Church Austin Adult Sponsors and Leaders to administer
non-prescription, over the-counter medication and prescription medication to the designated youth when such
medication is brought in the original prescription container.
Tylenol Acetaminophen Pain Relief Yes / No
Advil Ibuprofen Pain Relief Yes / No
Benadryl Antihistamine Allergic Reaction Yes / No
Benadryl Cream Yes / No
Antacid Tablets Calcium Carbonate Indigestion Yes / No
Immodium AD Loperamide Hydrochloride Diarrhea Yes / No
Cortizone Yes / No
Pepto Bismol Upset Stomach Yes / No
I hereby grant permission for my child to participate in all of the activities of the church.
I hereby grant permission for my child to leave the church premises under the supervision of an adult for church related activities.
I hereby grant permission for my child’s picture to be taken by First UMC Austin employees, volunteers, or other representatives
associated with church events & activities on and off the church premises to be used in church newsletters, brochures, displays and
web pages.
I hereby waive any claim against First United Methodist Church.

1. Have fun
2. Be at all events on time, stay for the duration of the event, don’t leave the designated areas for the event,
and participate fully in all activities planned.
3. Respect the physical and emotional well being of other youth and adults by “doing unto them as you
would have them do unto you.”
4. Respect the property of the places that we visit, the church property, and the property of other people.
5. Listen, respect, and follow the word of your adult leaders and report any injury or illness immediately
to them.
6. Respect the health of your body and others by not possessing or using any kind of weed, tobacco, alcohol,
pills, or other substances, unless it is a prescription drug and written permission has been granted by parent
or legal guardian.
7. Possession of or use of any fireworks, firearms, or other weapons is prohibited at any church related activity.
8. Do not engage in any inappropriate sexual behavior. You will not be with the opposite sex in the opposite
sex’s room, when on overnight functions.
9. Always remember who you are in Christ, and act and dress accordingly. Clothe yourself with Christ.
Remember you represent FIRST UNITED METHODIST YOUTH.
NOTE: In the case of any misconduct, the adult leaders reserve the right to call parents and send youth home
at the expense of the parents. The signatures below indicate that all understand the program and commit to
having the most positive experience.
Signature of youth
I hereby certify that I have read and fully understand all the permission I grant to First UMC Austin
and the Covenant of Conduct. Furthermore I understand the permission I grant to administer over-the-counter
and prescription medication.
Signature of parent or Guardian


Microsoft word - pallas_cv.doc

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