Youth Ministry Registration & Medical Release Form 2024-2025

Youth Ministry Registration & Medical Release Form 2024-2025
Name*

First NameLast Name
Grade 2024-2025*
Preferred Pronoun-Check one or more options for the set(s) of pronouns you want people to use to refer to you.*

he/him/hisshe/her/hersthey/them/theirsOther
School attending*
Student Date of Birth*
T-Shirt Size*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Cell:
Please enter a valid phone number.
Student Email:
example@example.com
Parent/Guardian Information
Parent/Guardian*

First NameLast Name
Email*
example@example.com
Cell Phone *
Please enter a valid phone number.
Media Release
Photo/Media Usage Permission * Bethlehem UMC includes photos and other types of media from church events, activities and participants on its website, publications and social media outlets. Please indicate in the box below if your child may have photographs and/or videos published through Bethlehem UMC's communications including but not limited to the website, social media and print publications. Images will be stored in a secure location and only authorized staff will have access to them. *
Signature of Parent/Guardian *

Clear
Today's Date*

MonthDayYear
Date

Medical Information
Emergency Contact (not parent) *

First NameLast Name
Cell Phone *
Please enter a valid phone number.
Any Allergies (medications/food/insects/etc):
Special Dietary Notes (gluten-free/dairy/vegetarian/etc.):
Are you currently taking any medications:
Are there any health/medical conditions that we should be aware of:
Please indicate any over the counter medications your student should NOT be given:
Date of Last Tetanus Shot:

MonthDayYear
Date
Has your child received a Covid-19 vaccine?
For your child’s safety and our knowledge, is your child:
Do you have any feedback that will help us provide a better classroom/group experience for your child:
(example: prefers not to read aloud, can be a little shy, etc.)
Insurance Information
Name of Insurance Company *
Policy Holder Name *

First NameLast Name
Insurance Policy Number *
Group Number
{name} has my permission to attend all youth activities sponsored by Bethlehem UMC (hereinafter the “Church”).

Permission to Participate and Release: I/We the undersigned have legal custody of {name}, a minor, and have given our consent for him/her/them to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any claim, loss, cost, damage, or expense arising out of any accident or other occurrence causing injury to any person or property during any outings or events. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such a person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent.

Medical Consent: In the event of an emergency, I/We hereby authorize an
adult leader of the Church, as an agent for me, to consent to an x-ray examination; medical, dental, surgical diagnosis treatment for {name}; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital. I expect to be contacted as soon as possible.

Transport Home Agreement: I/We understand that a member of the Church staff or the lead adult of our group may need to send a participant home as a result of illness or discipline problem. I/We understand if {name} is dismissed from an event or trip, I/he/she will be transported home at my/our expense.
Signature of Parent/Guardian*

Clear
Today's Date*

MonthDayYear
Date
BUMC YOUTH COVENANT (For All 6th-12th Grade Students)

All students participating in Youth Ministry (and their parents/guardian) will need to review and be familiar with this BUMC Youth Covenant. These expectations and rules are for the benefit of the Bethlehem's Youth Community to keep everyone safe and connected.
I understand that I am a representative of Bethlehem United Methodist Church and promise to honor my church community, God, the adult leaders and my friends with my choices and actions. I promise to be a participant in God’s work of making all things new and will treat every human being I interact with on this journey, seen and unseen, with dignity, respect, and the love of Jesus Christ.

RULES OF CONDUCT:

Be respectful to staff, peers and communities in which we interact.

Be a good steward of the facilities and/or grounds of our church or location visited.

Stay where you are suppose to be. Don't leave designated areas or grounds without permission.

Possession of alcohol, non-prescription drugs or tobacco products of any kind if not permitted.

Weapons, fireworks, lighters or explosives are not allowed.

Student drivers are not permitted.

NOTE: Students who fail to comply with these expectations may be sent home at their parents’ expense.
Student Signature*

Clear
Parent/Guardian Signature *

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Youth Ministry Registration & Medical Release Form 2024-2025

Parent/Guardian Information

Media Release

Medical Information

Insurance Information

BUMC YOUTH COVENANT (For All 6th-12th Grade Students)