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Youth Permission Slip

Name of Student *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Date of Birth

Name of Insurance *
ID Numbers *
Name of Primary Care Doctor *
Doctor's Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Doctor's Phone Number *
Medical Allergies or Conditions *Please describe any allergies or medical conditions the student has (including glasses or contact lenses) or state none.
Medications *Please include medications the student uses or state none.
Emergency Contact Name *
Emergency Contact Phone *
Parental Permission *
I give permission for my youth to participate in the above event. If emergency medical treatment is required, I give permission to the church staff or adult volunteers to obtain the services of a licensed physician. I will be notified as soon as possible concerning any such emergency. By typing my name here, I am electronically signing this form.
Media Release *
When participating in church activities, your child may be photographed for print, videotaped, or electronically imaged. Images may be used in promotional materials, news releases, and other published formats for Sterling UMC. The images are the sole property of Sterling UMC. If you do not want your child's image used, please check 'No."YesNo