HOLLAND’S UNITED METHODIST CHURCH YOUTH 2015MINISTRIES INFORMATION FORM
2016
Youth Name: _____________________________________________________________________________
Address: ________________________________________________________________________________
Street
Home Phone: ________________________________
City, State, Zip
Cell Phone: _______________________________
Email: __________________________________________________________________________________
Providing contact information grants permission to the HUMC Director of Youth Ministries
and the Youth Ministry Volunteer Staff to communicate directly with your youth
in matters related to information about and support for the Youth Ministry Program.
School: ____________________________________ Grade: ___________ Track (if applicable):_______
Birthdate: ________________
Age: ________ T-Shirt Size (please circle): A S
Father
Mother
AM
AL
AXL
AXXL
Emergency Contact
Name
Address
Home Phone
Cell Phone
Work Phone
Email
Photograph/Video/Image Permission
I grant authority and permission to Holland’s United Methodist Church (the “Church”) to use my youth’s name,
photograph, picture, video or other image (collectively, “Likeness”) in any print or digital publication (including
but not limited to the Church’s website and any websites that link from it), in any social media accounts, and in
all other print or digital mediums of communication and/or advertising, which may be used to promote the
Church’s ministries. I attest that I am the parent or legal guardian of the child listed above and that I have full
authority to consent to and authorize the Church to use his or her Likeness. I further acknowledge that neither
I nor my youth will receive financial compensation of any type associated with the use of his or her Likeness
Parent/Guardian Signature:______________________________ Date: _______________
HOLLAND’S UNITED METHODIST CHURCH YOUTH 2015MINISTRIES INFORMATION FORM
2016
MEDICAL RELEASE
Youth’s Name:
__________ Birthdate: _____/_____/_____
Insurance Company: __________________________________ Policy Number: ______________________
Name of the Insured on Policy: __________________________ Insurance Co. Phone #: (____) ____ - __________
PLEASE ATTACH A PHOTOCOPY OF THE INSURANCE CARD, FRONT AND BACK.
I authorize and grant permission to the above named minor (the "Participant") to participate in any and/or all Youth
Ministry activities and events at or through Holland’s United Methodist Church, Inc. (“HUMC”). I understand that this
consent is effective for all events from the date this form is executed until such consent is withdrawn by me in writing
I further authorize HUMC, and/or any of its agents, employees or volunteers, to take the Participant to a physician, dentist
or other health care provider for treatment of any injury, illness or sickness resulting from or occurring during any HUMC
activity or event. I acknowledge and agree that I am responsible for any and all medical bills.
I do hereby irrevocably and unconditionally release, remise, acquit, discharge, and agree to hold harmless HUMC and its
directors, trustees, pastors, sponsors, agents, employees, servants, officers, representatives, volunteers, affiliates,
divisions, subsidiaries, parents, predecessors, successors, heirs, assigns, administrators, executors and insurers from
any and all liability, claims, actions, causes of action or demands for injury, illness, sickness or death, as well as property
damage of any nature whatsoever, which have arisen or are now arising or hereafter may arise, and which are in any way
related to any HUMC activity or event.
_______________________________
(Signature of Parent / Legal Guardian)
Date:
____ / ____ / 20____
_______________________________
(Printed or Typed Name of Parent / Legal Guardian)
This authorization shall remain in full force and effect for one year from and after the date of execution of this document. In
the event of insurance or medical changes, please notify Holland’s Director of Youth & Children’s Ministries.
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Signed before me this day by ______________________________ (Name of principal).
Witness my hand and official seal, this the ______ day of ________________, 20____.
Official Seal:
______________________________
Official Signature of Notary
______________________________, Notary Public
Notary’s printed or typed name
My Commission Expires:______________________
North Carolina, Wake County
HOLLAND’S UNITED METHODIST CHURCH YOUTH 2015MINISTRIES INFORMATION FORM
2016
HEALTH INFORMATION FORM
Youth’s Name ____________________________Birthdate ___________ Blood Type_________
Please check any condition listed below that affects your child:
Y








N








Y









ADD/AHD
Asthma ________ (date of last attack)
Birth Defect
Blood Disorder
Cerebral Palsy
Cystic Fibrosis
Diabetes
Hearing Problem
N









Heart problem
Kidney/Urinary problem
Migraines
Muscle/Bone problem
Missing organ/Transplant
Seizures ________ (date of last seizure)
Sickle cell disease (not trait)
Vision problem Wears glasses? ______
Other Conditions (list below)
Please write a brief description of any “yes” answers.
_________________________________________________________________________________________________
Are immunizations up-to-date?  Yes  No (Explain) ___________________Date of last tetanus shot _____________
Is there any reason that your child’s activity should be restricted?  Yes (explain) _________________________  No
Allergic to:
Type of Reaction: (Circle)
Food: _________________________
Breathing Problems
Rash/Hives
Swelling
Vomiting
Medicine: _____________________
Breathing Problems
Rash/Hives
Swelling
Vomiting
Insect Bites/Stings: ______________
Breathing Problems
Rash/Hives
Swelling
Vomiting
Other: ________________________
Breathing Problems
Rash/Hives
Swelling
Vomiting
If your youth has an allergic reaction, are there specific instructions to follow in treatment?
List medicines (prescribed & over-the-counter) that your child takes at home and the reason:
List medicines or medical procedures that your child will require at events and the reason:
Physicians Name:
Physicians Phone: ________________________
Parent Signature: ________________________________
Date: _____________________