Youth Ministry Info and Release Form06.08.22 | by Stephen Haverstick Youth Ministry Info and Release Form Student Name* Parent(s) or Guardian(s) Name* Parent or Guardian Phone #*( ) - Choose best # for us to contact Parent or Guardian Email* Choose best email for us to contact Student Phone #( ) - Student Email Student Birthday * January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 Student Home Address* , AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY How can we best care for your child?Please share with us any information you'd like us as a youth leader team to know. This could be...a social scenario they struggle with, a mental health challenge, a special need, and/or the best way to connect with them personally. Share with us as little or as much as you'd like! Activity Permission* Yes No I do hereby certify that my child has permission to participate in all activities from August 31, 2023 through August 31, 2024. Any permissions granted by this form includes Safe-Sanctuary approved transportation. In-House Photo Permission* Yes No I do hereby give FUMC Hershey permission to use my child's photograph in newsletters and slideshows distributed or shown to the congregation at a FUMC Hershey event. Website and Social Media Photo Permission* Yes No I do hereby give FUMC Hershey permission to use my child's photograph on the church website, Facebook page, or Instagram account (understanding that his/her name will not be used). Digital Contact Permission* Yes Only the Youth Director has my permission No I do hereby give the Youth Director of FUMC Hershey and the Adult Youth Leaders (Small Group Leaders) permission to contact my child via text messages, phone calls, or Zoom calls. Terms and Conditions of Agreement* I have read and agree to these terms and conditions We (I) the parent(s) or legal guardian(s) of this student hereby grant our (my) permission for him/her to participate fully in the events and activities sponsored by or attended by First United Methodist Church of Hershey during the time period of August 31, 2023 through August 31, 2024. Authorization and permission is hereby given to said church (FUMC Hershey) to furnish any necessary transportation, food, lodging, for this participant during the excursions and activities of the youth ministry program. I understand all safety precautions will be taken at all times by First United Methodist Church and its agents during all events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold First United Methodist Church, its leaders, employees, and/or volunteer staff liable for damages, losses, disease, or injuries incurred by the participant who is the subject of this form. Furthermore, I, on behalf of my child, hereby assume all risk of personal injury, sickness, death, damage, and expense as a result of participation in recreation and work activities involved therein. I understand that in the event medical or dental intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached or the alternate contact person cannot be reached in an emergency, I hereby give my permission to a licensed Physician or Dentist at an office or hospital selected by the activity leader to hospitalize, to secure medical treatment and/or to order an examination, injection, x-ray, anesthesia, or surgery for my child as deemed necessary. I understand that First United Methodist Church does not carry accident or medical insurance on participating volunteers. I agree that my insurance company will be used for such medical care expenses. I am aware that I may be billed by the medical provider for any medical treatment expenses not covered by my insurance coverage and that I am responsible for the payment of any medical bills. Covenant of Expectations* I have read the Covenant of Expectations To truly create a safe place, our students and Youth Leaders collaborated to create a Covenant of Expectations with values and rules. A Covenant is a promise to one another to uphold these agreed upon values and rules. It is linked at the top right of this page as well as on the youth ministry home page. Parent/Guardian Electronic Signature* Medical ReleaseIf you'd rather submit a hard copy for this section, please contact the Youth Director and they will send you a form to complete. Insurance Company* Policy #* Group #* Other relevant information about coverage Please list any allergies (food and/or drug) or medical conditions below:* Emergency Contact Name* Emergency Contact Phone #*( ) - Parent or Guardian Electronic Signature for Medical Release* In the event my child needs medical care, I authorize the adult leaders to secure the needed medical attention for my child. Any permission granted by this form includes transportation time. Please leave this field blank.