AUTHORIZATION AND RELEASE FORM – FUMC Children’s Ministries - Jan. 07-Dec. 07

Date: ________________________________

Child:______________________________________ Sex:_______ Grade:________ Age:______

Birthdate:_______________

Address:____________________________________________ Zip:______________

Social Security #:______________________________

Name of Father or Male Guardian:______________________ Mother or Female Guardian:__________________________________

List ALL health restrictions:_____________________________________________________________________________________

List ALL medications to be taken and time to be taken (PLEASE SEND IN ORIGINAL CONTAINERS)

__________________________________________________________________________________________________________________

Physical Limitations:__________________________________________________________________________________________

Medical Insurance Co: (Please supply a copy of your insurance card)

__________________________________________________

Policy #:____________________________________________________________________________________________________

Phone number(s) where parents/guardians can be reached:

Mother/day:____________________ Mother/night:_______________________

Father/day:___________________ Father/night:___________________

Cell phone(s):_____________________________________

Other emergency names and numbers: ____________________________________________________________________________

____________________________________________________________________________________________________________

AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR AND RELEASE OF LIABILITY

To Whom It May Concern: ___________________________________has my/our permission to participate in activities in conjunction with the Children’s Ministry of First United Methodist Church, San Angelo, Texas, including but not limited to Sunday School, Church Childcare, Faith Weavers, Children’s Choirs, Summer Kid’s Club, Vacation Bible School, and other activities. I further understand that if my child will be participating in an activity off of the FUMC Campus, that further permission will be requested. Please seek any medical assistance needed while he/she is with this group. I/we, _______________________________, parent(s) or guardian(s) of ____________________________, a minor, do hereby authorize adult Children’s Ministry workers from FUMC of San Angelo, TX , agents for undersigned, to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is rendered under the general or special supervision of any physician or surgeon licensed under the provision of the Medical Practice Act on the medical staff of licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

I/we have read and understand the above document. By signing this document we hereby release First United Methodist Church of San Angelo, Texas from any and all liability for personal injury or damage to property.

_______________________________________________________________
Signature of Parent or Guardian Date Relationship to Minor

First United Methodist Church, Children’s Ministry
37 E. Beauregard
San Angelo, Texas 76903
325-655-8981
325-655-7039 fax