C1Youth Annual Authorization and Release Form

Youth Name *

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Father/Guardian Name

First Name Last Name

Phone Number *

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Email

example@example.com

Mother/Guardian Name

First Name Last Name

Phone Number *

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Email

example@example.com

Family Doctor Name *

Family Doctor Number *

Blood Type

Date of Last Tetanus Shot

Fully Vaccinated for COVID-19?

Yes No Choose not to answer

List ALL- medications to be taken and times to be taken (please send in original containers) Cont. Sheet Attached:

Physical limitations:

Medical Insurance Co.:

Main Carrier’s Name:

AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR AND RELEASE OF LIABILITY

To whom it may concern: Youth listed above has my/our permission to go on retreats, trips and other offsite events in conjunction with the Youth Ministry of Conway First United Methodist Church. Please seek any medical assistance needed while he/she is with this group. We, the parent(s) or guardian(s) listed above, of the youth listed above, a minor, do hereby authorize adult workers with youth from Conway First United Methodist Church, agents for undersigned, to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is rendered under the general or special supervision of any physician or surgeon licensed under the provision of the Medical Practice Act on the medical staff of licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. I also agree to pay for all charges associated with the care of my child. I knowingly release, absolve, indemnify and hold harmless Conway First United Methodist Church and its agents and employees from all claims that might result from any injury or death of any minor. I/We have read and understand the above document. By signing this document we hereby release Conway First United Methodist Church from any and all liability for personal injury or damage to property.

Signature

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As a representatives of Christ and of Conway FUMC events, we take seriously our responsibility to care for one another. This code represents affirmation of our concern for the well being of the total community. We covenant with each other to insure the safety of all, to make our time together most meaningful, and to care for the facility which we share.

1)Anything considered illegal under civil and criminal law in Arkansas is illegal for participants of any Conway FUMC event. This includes drug possession and use, alcohol consumption and possession by a minor and alcohol consumption on state property, possession of firearms, weapons or fireworks, etc. Tobacco use is disallowed as well. 2) Dress should be appropriate for a co-ed Christian environment. 3) All participants are expected to participate in the event in full and be at designated places at all times. 4) Visitation between males and females will be in designated areas ONLY.

5) We will respect the person, equipment and property of others as well as the public and private properties (living areas, meeting rooms, etc) in use during the event. 6) Any accidental damage to the property we are occupying will be billed to the family or the youth involved and will be the responsibility of the persons who caused the damage. Intentional damage is subject to additional penalties. 7) Cell phones, Radios, CD players, Mp3 players, etc. may be used during free time at levels that do not disturb others and cannot be heard outside the room in which it is being played.

I understand that violations of this covenant and/or other inappropriate behavior could require disciplinary action for youth and adults. Decisions about appropriate disciplinary action will be made by adult group leaders and Conway FUMC. Conway FUMC reserves the right to call parents or to dismiss any person who breaks this code of conduct and send them home at their own expense. I understand that First United Methodist Church of Conway will not be held responsible for any costs incurred due to medical treatment that is necessary nor from any damages to any property while at the event.

Parent/Guardian Signature *

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Newsletter

Yes, subscribe me to this newsletter.

Date

Youth Signature *

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From time to time we take pictures or record video during C1Youth activities. We would like your permission to use these pictures on our website, our social media, in our newsletter. We will not reference your child by name or provide any specific information regarding your child. We also will never sell these pictures; we will use them exclusively for Conway FUMC purposes.

Please take a moment to let us know your preferences regarding our use of photos of your children:

Child(ren)’s Name(s):

Parent/Guardian’s Name:

YES. I grant you permission to use photos/videos of my child on Conway FUMC’s social media, website, bulletin boards, and /or newsletter.

Yes

NO. Please do NOT use any photos/videos of my child.

No

Parent/Guardian’s Signature:

Clear

Date:

Date

CONWAY FIRST UNITED METHODIST CHURCH AUTHORIZATION AND RELEASE FORM

COVENANT OF CONDUCT

PERMISSION SLIP FOR PHOTOGRAPHING/VIDEOING YOUR CHILD