Kennesaw United Methodist Church: Medical Release Form
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Email *
First Name *
Last Name *
Grade *
Address *
City *
State *
Zip Code *
Phone Number *
Age *
Date of Birth *
MM
/
DD
/
YYYY
Parent/Guardian #1 First Name *
Parent/Guardian #1 Last Name *
Parent/Guardian  #1 Phone *
Parent/Guardian  #2 First Name
Parent/Guardian  #2 Last Name
Parent/Guardian  #2 Phone
Emergency Contact Name *
Emergency Contact Relation to Child *
Emergency Contact Phone *
Emergency Contact # 2 Name
Emergency Contact # 2 Relation to Child
Emergency Contact # 2 Phone
Please list all food and medical allergies, current medications, medical problems, or other pertinent information. Use reverse side if more space is needed. *
Insurance Company
Group Number
Policy Number
I give permission for my child to participate in activities with Kennesaw UMC programs both on and off church campus. *
I give permission for KUMC to use photos of my child's ministry involvement for promotional use, as well as website placement *
I give permission for my child to be transported to and from offsite activities and release KUMC and all adult sponsors or church staff from any liability in the event of any accident during ministry sponsored events. *
I give permission for my child to be examined, x-rayed, and treated by any licensed medical facility, office, hospital, or emergency facility if in the judgement of staff or representative from KUMC, emergency care, including anesthesia or surgery, is required to insure health and well-being of my child. I understand that every effort will be made to contact me. *
I understand this medical release/permission form is valid for one year and acknowledge that it is my responsibility to update as needed. *
By selecting YES, you acknowledge that this will serve as your electronic signature. *
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