EASLEY FIRST UNITED METHODIST CHURCH EASLEY, SC

PERMISSION/PHOTO/MEDICALI RELEASE

For June 1. 2023 - September 30, 2024
EASLEY FIRST UNITED METHODIST CHURCH EASLEY, SC
PARENTAL PERMISSION AND MEDICAL AUTHORIZATION FORM
Participant Name
Birth date

MonthDayYear
Date
I give permission for my child (named above) to attend the events. field trips, and service projects associated with Easley First United Methodist Church for the dates of June 2023- September 30, 2024, I further give permission for my minor to be transported to and from events by hired and volunteer drivers authorized by Easley First United Methodist Church. I also understand that Easley First United Methodist Church is not liable should injury come to my minor.

Medical Release I hereby authorize the Easley First United Methodist Church chaperones, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical or dental care. routine tests, treatment. and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic. medical procedure or treatment. and hospital care under the supervision. and upon the advice of or to be rendered by. a physicianor surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child. Activity Release I further give permission for my minor to participate in all supervised activities except as noted:
Signature of Parent or Legal Guardian

Clear
Printed name of Parent or Guardian
Date

MonthDayYear
Date
Parent Name(s)
Street Address
City
Zip
Parent Phone Number
Please enter a valid phone number.
Parent(s)/Guardian(s) Email address(es)
example@example.com
Youth Email address(es) (if applicable)
example@example.com
Emergency Contact Name(s)
Relationship to Participant
Emergency Contact Phone
Please enter a valid phone number.
Participant Name
Physician Name
Physician Phone
Medical Insurance Company
Medical Policy Number
Name of Medical Policy Holder
Dentist Name
Dentist Phone
Dental Insurance Company
Dental Policy/Group Number
Name of Dental Policy Holder
Please list any allergies to drugs, food, plants, insects, etc.
Please list any prescription medications to be taken by the participant (including what it is for, when it is taken, dosage and any procedures)
Please list any non prescription (over the counter) medication you do NOT want dispensed to your child
Please list any additional relevant information to participating in FUMC group activities(dietary needs, surgeries or serious injuries, chronic illnesses, epilepsy or diabetes, psychiatric counseling)
Information provided on this form will be kept strictly confidential.
ADDITIONAL INFORMATION: 2023/24 PHOTO RELEASE
Please note: Photos of minors will not have any names associated with pictures.

I (please check one below) _____grant ______do not grant permission for photos of my child/youth to appear on EFUMC web pages(including Facebook and church website CDs or DVDs. posters and bulletin boards.
I grant permission. (Type an x)
I do not grant. (Type an x)
Adult/Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Easley First United Methodist Church 204 S Pendleton Street Easley. SC 29640 (864) 859-4584
Should be Empty:

EASLEY FIRST UNITED METHODIST CHURCH EASLEY, SC

ADDITIONAL INFORMATION: 2023/24 PHOTO RELEASE