PERMISSION SLIP AND RELEASE OF LIABILITY

PAINESVILLE UNITED METHODIST CHURCH

71 NORTH PARK PLACE

PAINESVILLE, OH 44077

(440) 354-3642

Youth’s Name: ___________________________________________ Email Address: _______________________________________

Street Address: __________________________________________ City: _______________________________________________

To be filled out by youth:

I, ___________________________________________, am planning on attending ___________________________________________ on ___________________________ with adult leaders and other youth from PUMC. I agree to be responsible for my behavior, to respect the health and safety of others and myself, to relate to others and to use property and equipment in appropriate ways. I understand that I am not to bring any electronic devices on this trip, including but not limited to cell phones, walkmans, CD players, mp3 players, and personal digital assistants (PDAs). Leaders reserve the right to confiscate any of these items and return them prior to my going home at the end of the event. I also understand that no drinking, smoking, sexual conduct, or use of drugs is permitted on this church trip and that a violation of any of these will result in my immediate return home, at my own or my parents' expense.

Date: ___________________________ Youth Signature: _____________________________________________

To be filled out by parent/guardian:

I grant permission for ___________________________________________ to attend the ___________________________________________ on ___________________________ with adult leaders and youth of PUMC. I expect and hold my child to be responsible for his/her own actions during this event and travel to and from it, to be a cooperative member of the group so that this activity can be a wholesome means of fellowship. I have read the statement of responsibility above and have talked or will talk with my child about it. The church and adult leaders are held with no liability for unwise actions on my child's part.

Date: ___________________________ Parent/Guardian Signature:______________________________________

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MEDICAL RELEASE FORM

In case of emergency, I understand that every effort will be made to contact me at ___________________ or ___________________. If I cannot be reached, I hereby give the designated sponsor permission to act in my behalf in seeking emergency treatment for my young person, ___________________________________________, in the event that such treatment is deemed necessary by designated sponsor. 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 right to informed consent of treatment.

Parent/Guardian Name(s): _________________________________________Parent/Guardian Signature: ______________________________

If I/we are not available, please call relative or person below.

Name: _________________________________________ Relationship: ___________________ Phone: ___________________

Any allergies or medical conditions (medication, drug reactions, etc.): _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Any needed medication? Yes or No _____________________________________________________________________________________

INSURANCE INFORMATION:

Name of Insurance: ___________________________________________ Expiration Date: ______________________________________

Name of Holder: ___________________________________________ Contract #: __________________________________________