Family last name _______________

Family Last Name _________________________
First United Methodist Church of Allen
PARENTAL PERMISSION, PERSONAL LIABILITY & MEDICAL RELEASE

Liability Release--The undersigned, being the parent, guardian, or managing conservator of (youth name(s))
___________________________________
________________________________________ ________________________________________ Such Youth / Youths being under eighteen (18) years of age, does give permission for such Youth / Youths to participate in activities at, or sponsored by, the church named above (hereafter “the Church”). Being the legal and acting guardian of the Youth / Youths, and acting for myself and the on behalf of my youth(s), I release and hold harmless the Church and its respective staff, employees, volunteers, agents and representatives of any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the Youth / Youths and/or the undersigned resulting from any cause whatsoever occurring to the Youth / Youths and/or myself at any time while attending any activity, including travel to and from any activity, excepting only such injury or damage resulting from willful acts of these individuals. Medical Release— Being the natural parent (or legal guardian) of the above named minor Youth / Youths, I do
hereby make, constitute and appoint First United Methodist Church of Allen as my true and lawful, attorney in-
fact for the limited purpose of consenting to emergency medical treatment for the above named minor Youth /
Youths, which consent shall not terminate on my physical or mental disability subsequent to the date of
execution hereof. The foregoing consent shall be effective upon execution hereof and shall expire on this
________day of _________, 20____.
I voluntarily give permission for the Church to administer and/or obtain routine or emergency medical treatment
for my Youth / Youths as deemed necessary under the circumstances.
Any further treatment will require parental or guardian consultation and consent. I agree to indemnify and hold
harmless the Church and their respective staff, employees, volunteers, agents and representatives for any and
all claims, demands, actions, rights of action, and/or judgments by or on behalf of my Youth / Youths and/or me
arising from or on account of these procedures and/or treatment rendered in good faith and according to
accepted medical standards. I also agree that I will be responsible for any financial debt incurred by the
rendering of emergency medical treatment.
I can be reached at the following telephone numbers: Home Phone _________________________
Dad (Cell) ______________________
My Youth / Youths does/do not have any medical problems or special physical conditions, nor is my youth allergic to any medicines to my knowledge, other than the following: ________________________________________________________________________________________ ________________________________________________________________________________________ Insurance Company: ___________________________ Group Ins.#: ________________________________ Family Doctor: Name __________________________ Office Phone________________________________ Continued on backside
Medication Release— I give my permission for a Church designated individual (D.I) to give my Youth / Youths
over-the-counter medication as needed (i.e. Tylenol, ibuprofen, antihistamine, etc.) I give permission to a
Church designated individual to give my Youth / Youths his/her medication as directed below.
List all medications currently taking (Rx and over-the Counter), include: Dosage/Frequency/Reason for taking:
_______________________________________________________________________________________
_______________________________________________________________________________________
Parent Verification
Dispensing of Medication
of Medicine Given
Designated
Individual
Signature
Signature

Transportation Release— I give permission for my Youth / Youths to be transported either by Church-
provided transportation, commercial bus or by Church leaders’ private vehicles for field trips, mission trips,
Vacation Bible School, and/or other activities. If I do not want my Youth / Youths to use this transportation, I will
take sole responsibility to provide transportation or to see that my Youth / Youths do not attend the activity.

Marketing Release— I understand that my Youth / Youths 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 the Youth / Youths 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.
I, on my own behalf and on behalf of my Youth / Youths, hereby warrant that I have read this Release in its
entirety and fully understand its contents, and am aware that this form releases the Church from liability, and
have signed this form of my own free will. I understand that this authorization shall be effective continuously
from the date hereof until canceled by written notice to the Church. I agree to update this information in writing
as the need arises.
_____________________________________________ ________________________________________
Signature of Parent, Guardian or Managing Conservator Printed name
In witness by________________________________________________________
whereof have hereunto set my hand this ______day of ___________, 20___. Parents/Guardians, The first aid kit we take on youth trips contains some common over the counter medications. However, these medications can only be dispensed if the parent/guardian has given permission. Also, we will only give the suggested dose based on the age of the child as instructed on the medication container. For example, child says “I always take 3 Tylenol at home”. However, the recommended dose on the container is 2 tablets. Therefore we will only give 2 tablets, not 3. Giving less than the recommended dose is OK. Below is a list of over the counter medications available if your child becomes ill while on the trip. Please circle the medication(s) you are OK for us to give your child. Then sign below. Thank you so much Date___________________________ Youth Name___________________________________________________________ In the event, my child becomes ill; I give permission for her/him to receive the circled medications Sudafedrine (generic Sudafed) - for nasal congestion Diphenhydramine (generic Benedryl) - antihistamine for allergy/cold symptoms Loperamide (generic Imodium) for diarrhea Acetaminophen (generic Tylenol) - for general aches/pains Ibuprofen (generic Motrin) - for general aches/pains Meclizine (generic Dramine) - for nausea/motion sickness Emetrol – for nausea Tums - for indigestion/upset stomach Parent/Guardian Name_____________________________________________________ Parent/Guardian Signature__________________________________________________

Source: http://www.fumcallen.org/images/File/MedicalReleaseFormYouth.pdf