Attachment #1
Reinbeck United Methodist Youth
General Permission Form
Terry Plocher, Pastor
505 Spruce Street Reinbeck, Iowa
319-788-2310
PERMISSION FORM AND CONDUCT COVENANT
(This form MUST be completed in order to participate in overnight events or events held
off the Church Property)
I will treat other’s property, bodies, and feelings with respect. I will follow
instructions and clean up after myself. I will not participate in any illegal or sexual
activity during this event.
Youth Name: ______________________________
(signature)_________________________________
Date:___________________
+ + + + + + + + + + + ++ + + + + + + + + ++ + + + + ++ + + + ++ + + + ++ + + + +
PARENTAL CONSENT and MEDICAL RELEASE
I/We herby give permission for my/our child, ___________________, to attend and
participate in the Reinbeck United Methodist Church’s
___________________________________.
(specify name of event)
I/We, the undersigned, shall be liable and agree to pay all costs including transportation
should it be necessary for my/our child to return home due to medical reasons or other
reasons .I/We, the undersigned, also give permission for my/our child to ride in any
vehicle designated by the adult in whose care the minor has been entrusted while
traveling to and from and participating in this activity. I/We release, the Reinbeck United
Methodist Church, The Iowa Annual Conference of the United Methodist Church and, the
Reinbeck United Methodist Church planners, sponsors, and leaders from liability in event
of an accident.
Parent/Guardian Signature(s)________________________________
I can be contacted at these phone numbers during the event
_______________________________________________
Please provide the name and phone number of a backup contact
person__________________________________
Amended
9/19/2012
9