Emergency Contact Information – Parental Consent – Medical Authorization Form

    Student Information

    Home Address:

    Parent (Guardian) Information

    Home Address:

    Second Parent (Guardian) Information

    Home Address:

    To Whom It May Concern:

    The undersigned do(es) hereby give permission for our (my) Child:

    (“Participant”), to attend and participate in Events sponsored by Englewood UMC beginning in 2021.

    Liability Release:In consideration of Englewood Methodist Church (EMC) allowing Participant to participate in EMC sponsored activities, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless EMC, it’s directors, employees, volunteers and agents (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in EMC activities.

    (Check one of the following:)

    Furthermore, we (I) [and on behalf of our (my) minor Participant hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.

    Further, authorization and permission are hereby given to said Church to furnish any necessary transportation (within the limitation of Church insurance and the law), food and lodging for this Participant. The undersigned further hereby agree to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the neglect, willful or intentional acts of said participant, including expenses incurred attendant thereto.

    Medical Treatment Permission: We (I) authorize an adult, in whose care the minor has been entrusted to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

    Medical Insurance:

    Transportation Permission: The undersigned does also hereby give permission for our (my) child to ride in any vehicle driven by an approved ADULT chaperone while attending and participating in activities sponsored by EMC. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

    Early Return Home Policy: Should it be necessary for our (my) child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

    Photo Release: The undersigned does also hereby give our (my) consent for EMC to use photographs, videos and likeness in its publications, including its website, E-mails and associated social media pages. I release them from any expectation of confidentiality for the Participant.

    Electronic communications may be made via telephone, cell phone, text messaging, e-mail, the Church’s social media accounts, or other electronic means.

    Please note: All forms of communication with students will include parent/ guardians. At no time will Youth leaders communicate with students on a private level. Any student that messages leaders privately will be answered with a message containing two screened adults.

    I further understand that the ministries of EMC will use the Internet as an aid in teaching lessons during various events.

    I understand that it is the responsibility of the Parent(s) or Legal Guardian(s) to keep the information given on this form current.

    Parent or Legal Guardian

    Typing your name below is a legal signature.

    Second Parent or Legal Guardian

    Typing your name below is a legal signature.

    Please fill out these forms as well (if you haven’t already):