Orange Youth Info & Permission Form 2023-2024

Orange Youth Info & Permission Form 2023-2024
Youth's Legal Name*

First NameLast Name
Youth's Name (If different from legal name)

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Address (if Applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Youth's Health Insurance Provider
Primary Insurance Beneficiary
Medical Insurance Policy #
Medical Insurance Group #
Front of Insurance Card Photo
Back of Insurance Card Photo
Preferred Medical Center
Please note, that we may not be able to accommodate this preference in an emergency
Youth's Doctor
First and Last Name
Doctor's Office Phone Number
Date of Last Tetanus Shot
Vaccinated for Covid-19?*
Upload picture of youth's COVID-19 Vaccine Card
Does your youth have any allergies? Please be as specific as possible to help us keep your youth safe. *
Does your youth have any medical conditions that we should be aware of? Any accommodations needed as a result? Please be as specific as possible to help us keep your youth safe and included. *
Does your youth take any medications that we should be aware of? Please be as specific as possible to help us keep your youth safe. *
Does your youth have an IEP or other learning accommodations that would be helpful to know for a youth group learning environment? If so, please describe.*
Does your youth have any activity or swimming restrictions we should be aware of? Please be as specific as possible to help us keep your youth safe*
Have a schedule for your student's sporting events, performances, competitions, etc.? Upload a picture of it or digital file here:

Cancelof
Guardian's Information
Name*

First NameLast Name
Personal Pronouns

She/HerThey/ThemHe/HimLet me type...
If you chose "let me type":
Relationship*
Phone Number*
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
If offered by Orange UMC, I may be interested in...

A Parent/Guardian Small GroupOne-off topical workshopsParent Book ClubRecorded Workshop to Watch at My ConvenienceOther
If you checked other, please elaborate:
If you checked either of the workshop options, what topics would you be interested in learning more about?
Photo Release
Orange United Methodist Church blanks* (has/does not have) my permission to use my youth’s photograph publicly to promote the church or its events and programs. Unless signed below, I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.
Participation Permission
I give permission for my youth to attend on and off-site youth group outings with Orange United Methodist Church from September 2023 through August 2024. My youth has permission to be transported by church van and/or personal vehicles. I will not hold Orange UMC, its leaders, or volunteers responsible for any injury, losses, or damages that may occur during the event.
We ask each student participating in Orange Youth to read and agree to the following community agreement:

While participating in Orange United Methodist Church's (OUMC) youth group activities, I will do my best to seek God, love others, and love myself through my attitudes, thoughts, and behavior.

In order to uphold those values, I agree to:

Create a loving atmosphere through having a positive attitude and accepting others, while refraining from gossip, harmful language, and bullying.
Strive to resolve conflict in a timely, mature, & loving manner.
Respect instructions given by leaders.
Keep leaders informed of my whereabouts.
Stay in groups of at least 3 students.
Refrain from public displays of affection and respect personal boundaries.
Participate in all planned activities and give them my full attention, including by refraining from using personal electronics and cell phones.
Refrain from possession or use of alcohol, drugs, tobacco, or vapes.
Refrain from fighting, weapons, fireworks, lighters, or explosives.
Refrain from illegal activity of any kind.
Respect the facilities.
Stay out of sleeping areas that are not assigned to you.
Medical and Liability Release Statement
I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency during the activity, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary. I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. I understand all reasonable safety precautions will be taken at all times by Orange United Methodist Church and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I understand that leaders, employees, and volunteer staff do hold medications in a secure location during events but do not dispense medication. I understand that my youth will be responsible for seeking out and dispensing their own medication. I agree not to hold Orange United Methodist Church, its leaders, employees, and volunteer staff liable for damages, losses, disease, or injuries incurred by the subject of this form.
Parent/Guardian Printed Name
Parent/Guardian Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

Orange Youth Info & Permission Form 2023-2024

Guardian's Information

Photo Release

Participation Permission

Medical and Liability Release Statement