Arab First United Methodist Church2023-2024 Youth Ministry Permissions Waiver 

Please complete this form for each youth participant (to be used for all student activities that your child attends).

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Student Name:
Age:
Date of Birth:
MM
/
DD
/
YYYY
Current Grade:
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School Attending:
Student Address:
Student Cell #:
Permission to:
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Student email:
Permission to add to AFUMC student email list?:
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Can student sign themselves out of all student activities after being released by the responsible adult?:
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Please list any name(s) that student can be released to:
Parent/guardian name(s):
Parent/guardian address(es):
Parent/Guardian Phone Number(s):
Parent Email(s):
Student Insurance Info:
1. Provider:
2. Group #:
3. Policy #:
4. Name of Insured:
Student Medical Info: 
1. Pediatrician/ Doctor name and phone number: 
2. Dentist and phone name phone number:
Student allergies/other special needs/ medical needs?

Emergency Contact (other than parent/guardian(s) listed) and phone number:

I give permission for my child (named above) to attend the events, field trips, and service projects associated with the Youth Group of Arab First United Methodist Church: Also, known as AFUMC, (Arab, AL).  I further give permission for my child to be transported to and from events my child attends by hired and volunteer drivers authorized by the AFUMC. By typing my name below* I am agreeing to the statement above.

*Typing my name in the box provided is considered a legal electronic signature and agreement to the medical release.

Activity Release: I further give permission for my child to participate in all activities sponsored by the Youth Group of AFUMC. I understand that my youth participant named above may be participating in mission services projects, local service projects, and fellowship events during church youth events. I understand that during this period my youth may take part in activities such as: minor yard work, cleaning, painting, and other services consistent with the purposes of the church/ mission outreach. By typing my name below* I am agreeing to the statement above.

*Typing my name in the box provided is considered a legal electronic signature and agreement to the medical release.

Medical Release: In the event that my child should become seriously ill or injured during an activity organized by Arab First United Methodist Church or its youth department (provided a legal guardian is not present or cannot be reached immediately) a AFUMC Youth representative present at the time shall be directed to immediately contact the emergency medical response team for emergency medical treatment and/or transport to a medical care facility. I further expressly authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and/or hospital care under the general and special supervision, and on the advice of a licensed physician, surgeon, anesthesiologist, dentist or other qualified medical personnel acting under their supervision, for my youth participant named above, should the same become necessary because of illness or injury. I agree to be responsible for the admission, medical screening and for any drug or medical bills that may be incurred.

By typing my name below* I am agreeing to the statement above.

*Typing my name in the box provided is considered a legal electronic signature and agreement to the medical release.

Authorization for Media Release: Yes or No: AFUMC may post photographs and/or videos of my youth participant named above on the church website and/or the church /Youth Facebook Page or use photographs and/or videos of my youth participant named above in their publications and/or social media.

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