Online Forms | FIRST UNITED METHODIST CHURCH BOCA RATON

For the safety of all children and students we ask to have this release form filled out for the year for each participant. The form must be renewed to covers all activities, trips, and events from September 1 through August 31. You can complete the form either by the online form below, filling out the PDF form and emailing it to me, or printing the form and bringing in a hard copy. If you have trouble accessing the form online in these formats you can also pick up a hard copy from the church. Please also scan and email a copy of the front and back of your insurance card (or alternately drop off a hard copy of the insurance card).

FUMC Children and Student Release Form

Student Name

Date of Birth

Age

Grade

Sex

Student Cell

Home Address

City

Zip

Student Email

Parent / Guardian Name

Cell

Home Phone

Employer

Work Phone

Email Address

Parent / Guardian Name

Cell

Home Phone

Employer

Work Phone

Email Address

Emergency Contact Name

Relationship

Phone

Student Physician Name

Phone

Address

City

Zip

Date of last Tetanus Shot

Health Insurance Company

Policy Number

Phone Number

Please list ALL allergies

Any specific treatment required for allergies

List ALL current medication

Special Dietary Needs

Any other special information

Do you give permission for Adult Leaders, Chaperones and/or other Adult Representatives of First United Methodist Church to administer over the counter medications?

My child is physically fit and has the necessary skills to participate.

I/We, as parents or legal guardian(s) have given permission for him/her to be involved in the Children’s/Student Ministry activities of First United Methodist Church. I/We understand that involvement in these activities may require transportation in church owned vehicles operated by approved, licensed, and insured drivers of the Florida United Methodist Conference. In the event of any injuries or illness, I/we give permission to the licensed physician selected by the adult and/or designated representative of First United Methodist Church Children’s/Student Ministry event/activity to order routine tests, x-rays, and/or any other treatments deemed necessary by the licensed physician for my child who is named above. In the event of an emergency, of which I/we cannot be reached, I/we hereby give permission to the physician selected by the adult and/or designated representative of First United Methodist Church Children/Student Ministry to hospitalize, secure proper treatment for, to order injections and/or anesthesia and/or surgery for my child who is named above. Further, I/we agree to hold such persons harmless of any claims, demands, or suits for damages arising from the prudent giving of such consent under the supervision of a licensed physician.

By participating in any event or activity I agree that photographs and/or video may be taken of First United Methodist Church Children's/Student Ministry participants during events, activities, and classes by First United Methodist Church’s staff members, professional photographers, news media or volunteers. I waive the right to see or approve any publications that contain photographs and/or video of my child. I release First United Methodist Church and its representatives from responsibility for any harm or invasion of privacy that may occur or be produced by taking photographs and/or video of my child. I give First United Methodist Church and its representatives permission to use photographs or video that include my child in any and all media products for promotion, art, advertising, editorial or other purpose. This may include but is not limited to newsletters; both print and email, posters, brochures, ads, post cards and web pages. I certify that I have read the above authorization, release, and agreement, and fully understand what this document says.

Parent / Guardian Signature and Date

FIRST UNITED METHODIST CHURCH BOCA RATON

Making Disciples of Jesus Christ for the Transformation of the World

Category Archives: Online Forms

Child and Student Release Form