Medical Liability, Media Release, and Indemnity Form

Please complete one form per student.

Full Name*

First NameMiddle NameLast Name

Phone Number*

Area CodePhone Number

Mobile *

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail

Date of Birth*

DayMonthYear

What is your Gender?*

MaleFemale

I,*

Name

hereby give permission for*

Child Name

to attend events and participate in activities sponsored by First United Methodist Church of Nacogdoches, Texas including, but not limited to, meetings, sponsored events, retreats and field trips, whether held on site or off the FUMC facility. I understand that as a participant my child may be photographed or videotaped during normal activities and these photos/videos may be used in promotional materials. I understand that alternate forms of transportation, including the use of a church bus or carpooling may be used. I also give consent to emergency medical treatment to be administered to my child and for medical treatment decisions to be made by church leaders during sponsored events. I understand that all reasonable attempts will be made to contact me in the event of an emergency. I understand that FUMC Nacogdoches assumes no financial responsibility for medical expenses resulting from personal accidents or illness. I accept financial responsibility for the well being of the above named child(children) and authorize the group sponsor to seek needed medical help. As the parent or legal guardian of {fullName3} understand that the FUMC is not liable or responsible for any loss or damage to personal property that happens while participating in the trip. I also understand that the FUMC, its church staff, and/or chaperones bear no responsibility or liability for any accident or injury that may occur to my child while participating in this trip, and I agree to assume all liability and bear all financial responsibility. I also agree to indemnify the FUMC, its staff and/or chaperones for any damages caused by an alleged act or inaction by my child.

(General Note: Parents/Guardians will be contacted, if possible, prior to any medical attention being given.)

Do you take regular medication?*

YesNo

If Yes, please list

Have you been vaccinated against?

Hepatitis AHepatitis BTetanus

Have you ever had?

Have you ever had concussion?*

YesNo

Number of times

Approx date of last concussion

DayMonthYear

Have you ever had Head/Neck/Spinal injury?*

YesNo

If yes

Have you had Fracture/Dislocation in last 3 years?*

YesNo

If yes

Do you wear glasses?*

YesNo

Do you wear contact lenses?*

YesNo

What type of contacts do you use?

HardSoft

Do you suffer from asthma?*

YesNo

Do you ever take medication for asthma?*

YesNo

If yes

Do you bring your medication on trips?*

YesNo

Are you allergic to any materials?*

YesNo

If yes please list

Are you allergic to any types of food?*

YesNo

If yes please list

Do you have any medication allergies?*

YesNo

If yes please list

Physician Name

Physician Phone Number

Area CodePhone Number

Medicare Number

Do you have Private Health Insurance?*

YesNo

Insurance Carrier

Group/Plan

Policy Number

Contact Person 1*

Contact Number*

Relationship*

Contact Person 2*

Contact Number*

Relationship*

I Agree*

I have read, understood, acknowledge and confirm that the information is true and correct

Length of Release Coverage*

I want this release to cover Summer (May-August) of 2020 only.I want this release to cover 1 year from date of signing.I want this release to cover 5 years from date of signing.

Date*

Date

Full Name*

First NameLast Name

Signature*

First United Methodist Church Nacogdoches Medical/Liability/Photo and Video Parent Release Form

Medical Information

Health Insurance Information

Emergency Contact Details