L1UMC YOUTH REGISTRATION FORM

L1UMC YOUTH REGISTRATION FORM
ALL L1UMC YOUTH PARTICIPANTS (Adults or Youth) must have a completed registration form and a copy of their medical insurance card on file in the student ministry office. L1UMC Student Ministries Director and volunteers will have access to these forms for all events, trips, or outings.
PARTICIPANT INFORMATION
Participant Name

First NameLast Name
Address
Cell Phone
Email
example@example.com
Shirt Size (Adult)
Grade
School
Date of Birth

MonthDayYear
Date
PHOTO RELEASE: I consent to the photographing or filming of the participant listed above to be used for promotional purposes by First United Methodist Church of Lewisburg.
Parent/Guardian Initials
PARENT/GUARDIAN INFORMATION
Parent/Guardian #1 Name
Parent/Guardian #1 Home Phone
Please enter a valid phone number.
Parent/Guardian #1 Cell Phone
Please enter a valid phone number.
Parent/Guardian #1 Work Phone
Please enter a valid phone number.
Parent/Guardian #1 Email
example@example.com
Parent/Guardian #2 Name
Parent/Guardian #2 Home Phone
Please enter a valid phone number.
Parent/Guardian #2 Cell Phone
Please enter a valid phone number.
Parent/Guardian #2 Work Phone
Please enter a valid phone number.
Parent/Guardian #2 Email
example@example.com
EMERGENCY CONTACTS
(If parent/guardian cannot be reached)
Emergency Contact Name #1
Emergency Contact #1 Phone
Emergency Contact Name #2
Emergency Contact #2 Phone
MEDICAL INFORMATION
Participant Full Name
Name Coverage is Under
Health Care Provider
Policy Number
ID Number
Family Physician Name
Phone
ALLERGIES
SPECIAL NEEDS (physical, dietary, etc)

Medications

	-	MEDICATION LIST	-

TRANSPORTATION POLICIES (Initial for permission/agreeance)
I understand student drivers are not permitted to drive during an L1UMC event. Students may drive to and from meeting place only.
Initial
I understand it’s the sole responsibility of the parent/guardian to pre-arrange transportation to and from L1UMC events for my youth.
Initial
As the legal parent/guardian of the above youth, I give my permission for L1UMC and its representatives to transport my youth on outings and trips when such trips leave the L1UMC property.
Initial
STATEMENT OF RELEASE
I
Name of Parent/Guardian
, the legal parent/guardian of the above youth give my permission for him/her to

participate in Lewisburg First United Methodist Church (L1UMC) Youth Ministry events. I understand all reasonable safety precautions will be taken at all times by the L1UMC staff and volunteers. I have completed the information to the best of my knowledge. I understand there are risks inherent with all youth ministry activities and outings. I understand L1UMC, Director of Student Ministries, and other leaders are not liable for damages, losses, illness, or injuries incurred by my youth. In the event that an injury should occur, I give permission for my youth to receive any necessary medical treatment (including but not limited to: transportation to a medical facility, consultation with a medical professional, and any measures deemed necessary by attending personnel should my youth need such treatment before I can be reached.
Parent/Guardian Signature
Date

MonthDayYear
Date
Printed Name
Should be Empty:

L1UMC YOUTH REGISTRATION FORM

PARTICIPANT INFORMATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACTS

MEDICAL INFORMATION

STATEMENT OF RELEASE