Personal Information

Participant Name: ___________________________ Date of Birth:_______________

Address: _____________________________________________________________

Telephone: (H) ______________ (W) ______________ (C) ____________________

Email: _________________________

Contact Preference: ______mail _______telephone ______e-mail

Parent/Guardian or Emergency Contact: __________________ Relationship: ________

Address (if different) _________________________________________________

Telephone: (H) ______________ (W) ______________ (C) ____________________

Email: _________________________

Contact Preference: ______mail _______telephone ______e-mail

Medical Information

Insurance Company: ____________________ Group/ Policy Number: ___________________

Name of Insurance Carrier: ________________________________

Telephone: __________________ Doctor: ________________________

Allergies: _________________________________________________________________

Chronic Conditions: ________________________________________________________

Dietary or Activity Restrictions: ______________________________________________

Behavior or Learning Concerns: ______________________________________________

Date of Last Tetanus Shot: _______________ Wears Contact Lenses: ____________

I give the Lodi UMC Youth Program adult leaders permission to provide basic aid to my student including the availability of basic over the counter medication including pain reliever, antihistamine, etc. I also give the adult leaders permission to seek medical attention for my student even if they can not reach me or the emergency contact. This may include treatment, administration of medicine, clinical procedures or surgery. I understand that any fees would be the responsibility of me or my insurance company.

I understand all reasonable safety precautions will be taken at all time by Lodi UMC and its agents during events and activities. I agree not to hold Lodi UMC, its leaders, employees and volunteer staff liable for damages, losses, diseases, or injuries incurred through participation it the Lodi UMC Youth programs.

Lodi UMC paid and volunteer staff has permission to transport my student within a 20 mile radius of Lodi UMC. I understand that there may be occasions in which my child will be the only student left in the vehicle.

Liability Limitations

I understand that if my student is at Lodi UMC outside of scheduled activities (i.e. arrive early, stay after program is over) that the paid and volunteer staff will not be available to offer activities or monitor the actions of the students. I will not hold Lodi UMC or any of its agents responsible for my student’s behavior, safety or whereabouts.

Sign: _________________________________________ Date: ________

All information provided will be kept confidential.

Send comments concerning this web site to rschmie@chorus.net Last Updated: April 9, 2010