Personal Information:

* Required

Last Name:*
First Name:*
Middle Name:
Age:*
Birthdate:*

Year in School:*
Gender:*
E-Mail:*
Address:*
City:*
State:*
Zip Code:*
Home Phone:
Cell Phone:

Medical insurance company:
Policy #:
Mother’s Name:    Mother Cell:
Father’s Name:    Father Cell:
Emergency Contact:    Emergency Contact Phone:
Physician:    Physician Phone:
Dentist:    Dentist Phone:

Medical History

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken.

Check the following areas of concern for this student. If necessary, include more details at the end of this section:

1) For your child’s safety and our knowledge, is your student a …
Good swimmerFair swimmerNon swimmer

2) Does your child have allergies to …
PollensMedicationsFoodInsect Bites
If so, what specifically:

3) Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
AsthmaEpilepsy/Seizure DisorderHeart TroubleDiabetesFrequently Upset StomachPhysical Handicap

4) Date of last tetanus shot:

5) Does your child wear: GlassesContact Lenses

6) Current medications:

7) Please list and explain any major illnesses the child experienced during the last year:

8) Should this child’s activities be restricted for any reason? Please explain:

For your information, we expect each student to conform to these rules of conduct:

  1. No possession or use of alcohol, drugs, or tobacco.
  2. No students are permitted to drive on church events.
  3. No fighting, weapons, fireworks, lighters, or explosives are allowed.
  4. No offensive or immodest clothing is to be worn.
  5. No boys are to be in girls’ sleeping quarters and no girls in boys’ sleeping quarters.
  6. Participation with the group is expected.
  7. Respect property.
  8. Respect one another, staff, and adult leaders.
  9. Respect and comply with event schedules.

Students who fail to comply with these expectations may be sent home at their parent’s expense.

Activities may include, but are not limited to: cookouts, canoeing, swimming, basketball, roller skating, rollerblading, games in the park, soccer, bowling, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, Miniature golf, hayrides, Note: If you desire to limit your child’s participation in any event, please submit your wishes in writing to the Church prior to that event.

Name of Student* has my permission to attend all activities sponsored by Wooster United Methodist Church.

I*, give permission for my child*, to ride in a vehicle driven by an authorized adult to any WUMC outings and events during the current year.

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child.

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.

Parent/guardian signature*: (type your initials)

PHOTO PERMISSION
I give permission for my child’s photo to be taken by camera or video and used in church publications and on the church website.

Parent/guardian signature: (type your initials)

Parents, please let us know your preferred communication mode:
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