LIABILITY RELEASE AND PARENTAL CONSENT FORM

In consideration for being accepted by WILLIAMS MEMORIAL UNITED METHODIST CHURCH for
participation in UNITED METHODIST YOUTH FELLOWSHIP (UMYF) we, (I), being 21 years of age or
older, do for ourselves (myself) (and for and on behalf of my child-participant if said child is not 21
years of age or older) do hereby release, forever discharge and agree to hold harmless WILLIAMS
MEMORIAL UNITED METHODIST CHURCH it’s directors, staff and volunteers from any and all liability,
claims or demands for personal injury, sickness or death, as well as property damage and expenses,
of any nature whatsoever which may be incurred by the undersigned and the child-participant that
occur while said child is participating in UMYF or any trip or activity connected with participation in
UMYF
Furthermore, we (I) (and on behalf of our (my) child-participant if under the age of 21 years)
hereby assume all risk of personal injury, sickness, death, damage and expense as a result of
participation UMYF or any trip or activity connected with participation in UMYF.
Further, authorization and permission is hereby given to said church to furnish any
necessary transportation, food and lodging for this participant. The undersigned agrees to be
responsible for all costs associated with the transportation, food and lodging so provided.
Further, authorization and permission is hereby given by the undersigned to said church to
photograph participant and use the photographs and likenesses of participant in any manner or
media that it chooses, including but not limited to newsletters, websites, or advertising.
The undersigned further hereby agree to hold harmless and indemnify said church, its
directors, employees and agents, for any liability sustained by said church as the result of the
negligent, willful or intentional acts of said participant, including expenses incurred attendant
thereto.
(If the participant has not attained the age of 21 years):
We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my)
permission for him (her) to participate fully in MYF. In case of medical emergency, we(I) understand
every effort will be made to contact a parent or guardian. The information provided on the second
page of this document regarding medical history and condition is complete and correct to the best
of my knowledge. In the event we(I) cannot be reached, we(I) hereby give permission to the
physician selected by the Williams Memorial United Methodist Church staff, representatives, or
officers, to hospitalize, secure proper treatment, and to order injection, anesthesia or surgery for my
child, as named above.
Further, should it be necessary for the participant to return home due to medical reasons,
disciplinary action or otherwise, we (I) hereby assume responsibility for all transportation costs.
Only participant need sign if 21 years of age or older. If under 21,both parents must sign
unless parents are separated or divorced, in which case the custodial parent must sign.

________________________________________ __________________________________________
Participant’s name
Participant

Date.

________________________________________ __________________________________________
Participant’s address

Father
 Date

________________________________________ __________________________________________
Participant’s telephone

Mother

Date

________________________________________ __________________________________________
Parents/Legal Guardian telephone
Legal
Guardian

Date

________________________________________
Emergency phone numbers

Medical History and Condition

Participants Name: _______________________________________________________________

Participants Doctor: ___________________________________________________________________

Participant’s Date of Birth: _____/______/_______

Height_____________

Weight______________

Parent(s) or Guardian’s Address:

Insurance Company and Policy #: __________________________Effective Date________________

1. Is there a history of chronic infection of nose, throat, ears, sinus, or lungs? __________
If so, what? ____________________________________________________________________
2. Is there a history of heart pathology requiring restricted activity?
_____________________________
3. Is this person subject to any skin disease? _______________
4. List any allergies to drugs, medications, or food:
________________________________________
5. Has there been recent illness, or exposure to contagious disease?
___________________________
If so, what? _______________________________________________________________________
6 Is this person subject to fainting? ______ Convulsive Seizures? ______ Diabetic?
 _______ Nose Bleeds______ Asthma? ______
What medication is prescribed for the preceding condition?
______________________________________________________________________
7. Limitations of activity?
______________________________________________________________
8. Please list any medication(s) the participant is currently taking?
____________________________
______________________________________________________________________________
9. Date of last tetanus shot? ________________________________

_____________________________________
Signature of parent or guardian

Subscribed and sworn to before me this _____

___________________________________________
(month and year)

_______________________________________________
State of Texas NOTARY PUBLIC

County of ____________________________
My Commission
expires:_____________________________