LUMC Medical Release

LUMC Medical Release

Wed, 2012-02-22 10:02 |

angelabecek

Please complete the following information. When you receive your e-mail confirmation, parents need to sign it and return. To make changes, please recomplete the form, this will then be valid for another year from the new submission date. Thank you!

This form is valid for one year.

Name: *

Birth Date: *

Youth E-Mail:

Youth Cell Phone:

2nd Youth Name:

Birth Date:

2nd Youth E-mail:

2nd Youth Cell Phone:

Parent/Guardian Name 1: *

Best E-mail: *

Parent 1 Cell Phone: *

Parent/Guardian Name 2:

Parent 2 Cell Phone:

Street address: *

City: *

State: *

ZIP: *

Home Phone: *

Emergency Contact: *

Emergency Contact Phone: *

2nd Emergency Contact: *

2nd Emergency Contact Phone: *

Do you give your child permission to participate in activities with the Leesburg United Methodist Youth Ministry: *

Yes

No

Do you give permission to any adult chaperone representing the Leesburg UMC Youth Group to act in your behalf if you can't be reached?: *

Yes

No

Do you give permission for your child, to attend activities organized by LEESBURG UM CHURCH from June 4, 2012 through June 3, 2013?: *

yes

no

Do you give permission for images of your child(ren), to be used for promotional material (w/out names attached or tagged) at church, on website and Facebook?: *

yes

no

Health Insurance Company: *

Policy#: *

Group Number, if applicable:

Other/Special Notes:

Neighborhood (for carpooling)::

Can your information be printed in youth directory (not online)?: *

Yes

No

Contact Information only will be published.

Special Notes/Health Concerns/Allergies/Etc.:

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