New Town Youth Annual Consent and Emergency Information Form

Annual Consent and Emergency Information Form

New Town United Methodist Church Youth Ministry
Student Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Gender at Birth*
Name of School
Grade*
Student mobile number (if applicable)

Area CodePhone Number
Student Email
example@example.com
Parent/Guardian Name (1)*

First NameLast Name
parent mobile phone*

Area CodePhone Number
Parent/Guardian Name (2)

First NameLast Name
parent mobile phone

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Allergies/Special Health Considerations*
Are any of these allergies life threatening?*
Emergency Contact*
name/relationship
Emergency Contact Phone*

Area CodePhone Number
Insurance Company*
Policy Number*
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my rightto informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.
Parent/Guardian electronic signature*
I give permission for my child to participate in New Town Youth events. I release New Town UMC and invdividuals from liability in case of accident during activities related to New Town UMC as long as normal safety procedures have been taken.
Parent/Guardian electronic signature*
Please verify that you are human*
Should be Empty: