2025-2026 Galloway UMC Medical Information / Photo Release Form

Galloway United Methodist Church Medical Information / Photo Release Form

Fill out your medical information carefully and accurately. All students attending trips off-site MUST have a current waiver. All waivers must be updated every year.
Student Name*

First NameLast Name
Parent(s) Name*

First NameLast Name
Parent(s) Name

First NameLast Name
Parent Phone Number*

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Student Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In Case of Emergency
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home phone*

Area CodePhone Number
Work phone

Area CodePhone Number
General Medical History
Significant Medical History (surgery, injuries, serious illness):
List any Medical Problems (asthma, seizures, headaches):
List any medication taken regularly:
List any allergies:
Medical insurance details
Name of Insurance Company:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Policy Number:*
Expiry Date:

DayMonthYear
I give my consent for Galloway UMC Youth Group Counselors, Staff, Employees and Chaperones to take my youth/student listed above on off-site outings and trips including transportation in church operated vehicles, whether such vehicles be church owned, rented or personally owned vehicles.*

YesNo
I give my consent to the Galloway UMC Youth Group counselors, Staff, Employees and/or qualified medical personnel to act on my behalf in securing and administering necessary emergency medical treatment for the above named youth/student..*

YesNo
I give permission for my youth/student to be shown in photos and videos. These photos and videos can be used to share about the trip and to promote Galloway UMC’s ministries.*

YesNo
Indemnification: The undersigned hereby shall indemnify and hold harmless Galloway United Methodist Church, its administrators, its Trustees, its officials, employees and agents from and against any and all liabilities, judgments, settlements, losses, costs, charges, causes of action, including attorney’s fees, incurred by Galloway United Methodist Church, its Trustees, administrators, officials, employees and agents as a result of any claim, demand, action, or suit resulting to any bodily
injury (including death), loss of property, damage caused by, arising out of, related to, or associated with this agreement.

Waiver: The undersigned knows, understands, and acknowledges the risks and hazards associated with the activities undertaken in contemplation of this agreement and hereby assumes any and all risks and hazards, of Galloway United Methodist Church, its Trustees, administrators, officials, employees or agents for any bodily injury (including death), loss or property damage incurred by the participant (Youth) and hereby irrevocably releases and discharges Galloway Memorial United Methodist Church its Trustees, administrators, officials, employees or agents from any and all claims of liability arising out of or associated with the activities undertaken in contemplation of this agreement.

I further recognize the above-named youth/student is at higher risk of contracting COVID-19 with participation in youth group or other Galloway UMC activities. With full awareness and appreciation of the risks involved, I, for myself and on behalf of the above-named youth/student, hereby forever release, waive, discharge, and covenant not to sue Galloway United Methodist Church, its Trustees, administrators, officials, employees, assigns or agents from any and all liability, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, or injury, including death, that may be sustained by myself or by the above-named youth/student related to COVID-19.

By submitting this form, I confirm that the above information is accurate as to the best of my knowledge.
Signature*

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Galloway United Methodist Church Medical Information / Photo Release Form

In Case of Emergency

General Medical History

Medical insurance details