First United Methodist Church
325 E Franklin Street - Appleton Wisconsin 54911
Youth Ministry
Registration and Consent to Treatment
I,
, parent or legal guardian of
do hereby consent to any hospital, medical, or surgical care and treatment
and the administration of anesthesia, determined by a qualified physician
to be necessary for the welfare of my youth while said youth is under the
care, custody, and control of First United Methodist Church, and I am not
reasonably available by telephone to give consent. I further release
First United Methodist Church and its adult leaders from any liability or
claims resulting from my son's/daughter's participation in any First
United Methodist Church youth activities.
Parent signature
Date
Family address
Parents' name and phone
Work phone
Youth's birth date and grade
Date of last tetanus shot
List any allergies to foods or drugs
Family physician and phone
Insurance company, phone number, and policy number
Expectations
- You will treat EVERYONE you come into contact with in a loving and
respecting manner.
- Anyone found in possession or consumption of alcohol or illegal
drugs will be sent home at their own expense. Use and/or
possession of tobacco products are not allowed.
- Males are not allowed in female rooms; females are not allowed in
male rooms.
- You will have a good time.
- If a youth does not follow the rules and expectations set forth by
Andy Wilson and the youth ministry staff of First United Methodist
Church, the above youth will be sent home at the expense of their
parents.
I have read and agree to abide by the expectations stated above.
Youth signature
Date
Please list any special dietary needs:
