Parental Consent and Medical Release

Name of Child/Youth

Child/Youth Birthdate

Does your child/youth have allergies?

Yes No

If yes, please list allergies, severity, and treatment:

Any health issues?

Are there any medications your child/youth is currently taking regularly?

Yes No

If yes, please list them here:

AUTHORIZATION FOR OVER-THE-COUNTER MEDICATIONS The following is a list of medications we will have available in our first aid kit. Please check which medications may be used to treat your child. You will be contacted prior to any medications being given to your child.

OTC Medications

Tylenol (acetaminophen) Advil (ibuprofen) Bacitracin Benadryl (diphenhydramine) None

Home Address

Mailing Address (if different)

Parent/Guardian 1 Name

Phone

This address will receive a confirmation email

Parent/Guardian 2 Name

Phone

Parental Consent

As the parent/guardian of

I understand that my child/youth may be participating in a number of activities for June 3, 2026 – June 3, 2027, which carry with them a certain degree of risk. These may include swimming, boating, hiking, manual labor, sports, theme parks, and any number of other physically demanding activities included in fellowship, service, and other church-related outings and events. I give my consent for my child to participate in these activities.

I represent that my child/youth is physically fit and has the necessary skills to participate safely in these activities.

I understand and give consent for my child to travel to and from these events in transportation provided by approved HSFUMC volunteers/drivers over the age of 21.

My child/youth has restrictions on the following activities:

MEDICAL TREATMENT AUTHORIZATION

It is my understanding that HSFUMC will attempt to notify me in case of a medical emergency involving my child/youth. In circumstances where necessary, I authorize the church to seek appropriate medical attention, including but not limited to calling EMS or taking my child to an urgent care facility or ER. I also give my permission to the doctor or other health-care professional to provide the medical services he or she may deem necessary. HSFUMC will NOT pay for any medical expenses. I will notify HSFUMC if I feel my child/youth should not participate in any activities, for health reasons or any other concerns.

Name of primary insured:

Insurance Company:

Policy/Group #

Additional Consent

I give my consent for use of photographs of my child/youth on the website or any other promotional literature.

I understand that in the event of conduct and/or behavioral problems with my child/youth that cannot be rectified, I will personally come get my child/youth, arrange for someone to come get my child/youth, or arrange for the individual transportation of my child/youth home from this event.

Electronic Signature of Parent or Guardian

Parental Consent and Medical Release

Description

Please Fix the Following