Medical/Permission Release Form

Medical Release/Permission Slip for The Point Church of Clearwater

Event: All Events from January 1, 2023 through December 31, 2023
Parent E-mail*
Name of Minor/Participant:*

First NameLast Name
Name of Parent/Guardian:*

First NameLast Name
Name of Parent/Guardian:*

First NameLast Name
Parent Phone #:*

Area CodePhone Number
Emergency Contact:*

First NameLast Name
Relation To Minor:*
Emergency Phone:*

Area CodePhone Number
Authorization To Consent To Treatment:
I/we, the parent/guardian, of the above-named minor/participant, do hereby authorize all sponsors in charge from First United Methodist Church Fairfield as agents for the undersigned to consent to an x-ray examination, anesthetic, medical or surgical diagnosis for the treatment and hospital care which is deemed advisable by physician and surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital whether or such diagnosis or treatment is rendered at office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific consent to any and all diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his best judgement delivered to said agents.
Please Select:*

I, (The Parent/Legal Guardian) Give ConsentI, (The Parent/Legal Guardian) Do Not Give Consent
I/we, the parent/guardian, also understand that I/we will be responsible for all fees pertaining to any treatment or medical decisions that are decided upon. The Church/Staff/Volunteers are NOT responsible for any medical fees that may occur.
Please Select:*

I, (The Parent/Legal Guardian) Agree To These TermsI, (The Parent/Legal Guardian) Do Not Agree To These Terms
Picture/Image and Video Release Consent:
Further, I consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of the minor/participant during their participation in any activity, event or trip to be used, distributed, or shown as FUMC Fairfield sees fit including but not exclusive to: slide shows, church web site, social and print media. (When used in the public realm identifying information will be used responsibly e.g. names will not be attached to specific pictures or video images on the church's website.)
Please Select:*

I, (The Parent/Legal Guardian) Give ConsentI, (The Parent/Legal Guardian) Do Not Give Consent
Insurance Co:*
Policy No:*
Family Doctor:*
Doctor Phone #:*
Parent/Guardian Signature:*
Date of Signature:*

MonthDayYear
State of
County of
On ________________, before me, _____________________, personally appeared _________________________ and prove in a satisfactory evidence to be the person indicated on this document. I know or have identified this person by proper identification, and I acknowledged that he/she excuted the same for the purpose there in contained.

I confirm under PENALTY OF PERJURY under the laws of the State of Florida that all information in this document is accurate and true.

___________________________________

Signature of Notary
Should be Empty:

Medical Release/Permission Slip for The Point Church of Clearwater

Authorization To Consent To Treatment:

Picture/Image and Video Release Consent: