FUMC Release Form

A form for you to complete our Conduct & Responsibility Guidelines, the Chaperone/Volunteer Guidelines, as well as the Medical, Photo & Hold Harmless Release Forms.

Basic Information

Participant's Name(Required)

the name of the youth or child that will be participating in either our His Kids or Pursuit Student Ministry

First Last

Age(Required)

Grade(Required)

if during the summer, the grade they will be going into

Birthdate(Required)

Participant's Cellphone

if applicable

Who can pick up your student?

list those individuals who are allowed to pick up your student

Address(Required)

Street Address Address Line 2 City State ZIP Code

Participant's Health & Medical Information

Participant's General Health is:

Excellent

Good

Fair

Poor

Fair or Poor Health explanation

please explain why the participant’s health is fair or poor

Medical Issues(Required)

share any medical conditions, medications, &/or allergies the participant might have; enter “n/a” if this does not apply

List any medical conditions for which the participant is currently being treated:(Required)

enter “n/a” if this does not apply

List any medications the participant is currently taking:(Required)

enter “n/a” if this does not apply

List any medications or substances the participant is allergic to:(Required)

enter “n/a” if this does not apply

Medical Insurance Information

enter “n/a” if any of these do not apply

Medical Insurance Carrier(Required)

Policy or Group #(Required)

Personal ID #(Required)

Family Physician(Required)

Physician's Office Number(Required)

Parental Information

Mother's First & Last Name

Father's First & Last Name

Mother's Cell Phone(Required)

Father's Cell Phone(Required)

Mother's Email(Required)

Enter Email Confirm Email

Father's Email(Required)

Enter Email Confirm Email

First Emergency Contact Name(Required)

First Contact Relationship(Required)

Cell Phone(Required)

Work Phone

Second Emergency Contact Name(Required)

Second Contact Relationship(Required)

Cell Phone(Required)

Work Phone

Other Emergency Contact Name(Required)

Other Contact Relationship(Required)

Cell Phone(Required)

Work Phone

Release Section

By completing this form you are acknowledging that you (& your student) have read & understood the Conduct & Responsibility Guidelines, the Chaperone/Volunteer Guidelines, as well as the Medical, Photo & Hold Harmless Release Forms.

Medical, Hold Harmless, & Photo Release Authorization(Required)

Do you; (1) give your permission for an attending physician or hospital to administer medical care if deemed necessary by the leader(s) of First United Methodist Church of Panama City and the physician or hospital staff during the event. (2) I, therefore, do hereby release from all claims and forever hold harmless the directors, officers, agents, and employees of First United Methodist Church of Panama City, from any and all claims and demands for personal injury, sickness, and death, as well as property damage and expenses, of any nature, incurred by myself (or my child under 18 years of age). (3) And furthermore, give FUMC rights & permissions to photo/video & distribute as they see fit the participant. And the participant discharges and agrees to save harmless First United Methodist Church of Panama City from any liability for violation of any personal or proprietary right that I may have in connection with said images and with the use thereof.

Yes, I give permission to electronically sign a First United Methodist of Panama City Hold Harmless Form

No, I will be contacting you to complete a form in person

Electronic Signature Verification(Required)

I agree and understand that by completing this form that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.

Yes

No, I will be contacting you to complete a form in person

Printed Name(Required)

of the parent/guardian who is completing this form

First Middle Last

Initials(Required)

Today's Date(Required)

Signature(Required)

use your mouse (or finger on a touchscreen device) to sign your name

This field is for validation purposes and should be left unchanged.