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West Allis First UMC Youth
Fellowship
Individual Medical Form Youth Name ___________________________________________________________________ Nickname: ____________________ Date of Birth _________________________ Parents / Guardians :______________________________________________________________ The purpose of this form is to ensure consent from parents for participation in all activities with West Allis First United Methodist Church youth fellowship. It is also a form granting permission for the treatment of minors who become ill or injured when the parents or guardians cannot be reached to give consent for treatment. Every reasonable attempt will be made to contact the parent(s)/guardian listed below. Emergency Information: (Person to contact in case of emergency) Name_____________________________________Relation to Participant_____________________ Daytime Phone __________________ Evening Phone__________________ Cel _________________ Address:________________________________________ City: ____________________________ Family Doctor’s Name ___________________________ Family Doctor’s Phone __________________ Insurance Information: Participant is covered by a medical insurance policy: Yes No Insurance Company Name _________________Name of Policy Holder__________________________ Group Policy Number _____________________ Authorization Phone Number ____________________ Health History: Allergies/special health concerns/needs: __________________________________________________ Medication(s) you can NOT take: ______________________________________________________ Medication(s) being taken: ___________________________________________________________ Special Dietary Needs: _____________________________________________________________ Any Medical History that needs to be noted: _______________________________________________ ______________________________________________________________________________ Permission/Release/Authorization (For participant’s under 18) I, the undersigned parent or guardian, do hereby grant permission for my child, __________________________, to attend and participate in any West Allis First UMC youth fellowship activities. In order for my child to receive necessary medical treatment from the medical staff and/or the staff physicians of the hospital and clinics in case of injury or illness, I hereby authorize the event leaders to obtain and consent to medical treatment for my child for such injury or illness during the any West Allis First UMC youth fellowship activities. I hereby release and discharge volunteer staff, West Allis First United Methodist Church and its representatives, employees, and agents from any and all debts, judgments or suits of any kind which may arise or be occasioned as a result of participant’s participation in all any West Allis UMC youth fellowship activities. I further acknowledge and understand that by participating in these activities there is a possibility of physical illness or injury that my child is assuming the risk for such illness or injury by her/his participation. Payment of any medical bills will be paid by me or my insurance company. We, the guardian and the participant, also give the Wisconsin Conference permission to use the participant’s image in any publication materials that might be used to promote ministry in the future. Signature of Parent/Guardian Signature of Participant: ______________________________________ |