*Student Information

Full Name_________________________________ Birthday_______________ Grade____________

Address____________________________________ City/State/Zip ____________________________

*Parent Information

Mother’s Name ______________________ Phone (hm/wk) ____________________________

Father’s Name _______________________ Phone (hm/wk) ____________________________

*Permission By Parent

I GIVE MY PERMISSION FOR OUR YOUTH (name above) TO PARTICIPATE WITH THE FIRST UMC STUDENT MINISTRY IN ALL EVENTS.

_______________________________ ________________

Parent/Legal Guardian Signature                         Date

*Medical Info.

Family Physician ______________________ Phone ______________________

Allegies (i.e. Penicillin, Poison Ivy, Bee Sting) ______________________________________

Date of Last Tetnus Shot ________________________ Other Immunizations ______________

Any other medical information that would be helpful for us to know: _____________________ ___________________________________________________________________________

*Consent For Treatment

I (We) hereby give permission and written consent to the hospital selected by FUMC Student Ministry leaders and or church staff to provide any medical treatment and/or surgical treatment to our youth named above as deemed necessary for the care of any injury or illness.

__________________________________ ___________________________________

Parent or Legal Guardian (signature)                                                  Date

Medical Insurance Carrier ________________________ Policy #________________________

Emergency Contact Other than Above _________________________ Phone #_____________

*The Medical Information and the Consent for Treatment only need to be filled out if you do not currently have one on file. This means that if in the last year you have not filled one out please do so!