First United Methodist Church - Lancaster Pa

Engaging, Inspirational, Multigenerational

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Leader Medical Release Form

 

Effective: 2009-2010 School Year                             * Indicates a Required Field

 

*Last Name: 

*First Name: 

*MI: 

 

*Age: 

*Birthday:   (example: 10/28/1970)

*Gender:   

 

*Email: 

*Address: 

*City: 

*State: 

*Zip: 

 

*Emergency Contact: 

*Emergency Phone # and type:  (example: 717-394-7231)

                                                   Home     Work     Cell 

*Insurance Co: 

     *Policy #: 

*Physician: 

     *Office Phone #:   (example: 717-394-7231)

*Dentist: 

     *Office Phone #:    (example: 717-394-7231) 

_______________________________________________________

MEDICAL 

Check the following areas of concern. If necessary, add any details below:

*1. For your safety and our knowledge, are you a...

      good swimmer     fair swimmer     non-swimmer

 

*2. Do you have allergies to...

      pollens     medications     food     insect bites

 

*3. Do you suffer from, or have ever experienced, or are being treated currently for any of the following:

      asthma     epilepsy/seizure disorder     heart trouble    

      diabetes     frequently upset stomach     physical handicap

 

*4. Date (month & year) of last tetanus shot:   (example: 10/09) 

 

*5. Do you wear:     glasses     contact lenses

 

6. Please list and explain any major illnesses you experienced during the last year and add any additional comments:

    

 

7. Should your activities be restriced for any reason? Please explain:

      

(If necessary, describe in detail the nature and severity of any physical and/or psychologial ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which you are subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification by adding your comments below. Include names of medications and dosages that must be taken.)

   

_______________________________________________________

 

For your information, we expect you to follow these specific guidelines of conduct while leading our youth...

  • No possession of or use of alcohol, drugs, or tobacco.
  • Physical and verbal fighting will not be accepted or tolerated.
  • No possession of or use of weapons, fireworks, or explosives of any kind.
  • Dress appropriately; offensive t-shirts or immodest clothing is unacceptable.
  • In the case of overnights, guys and girls will sleep in separate and segregated rooms.
  • We ask that everyone respect our church facility and the property contained within our building.
  • Respect and Love each other, our students, and our committed team of adult volunteers.
  • Respect and comply with event schedules.

*I have read the rules of conduct and the above evaluation of my health. I agree to abide by the stated personal limitations and code of conduct.

 

I understand that there are inherent risks involved in any ministry or athletic event, and I herby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or propery that may occur during the course of my involvement. In the event that I am injuried and require the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for dameages arising from the giving of such consent. I also acknowledge that I will be ultimately responsible for the cost of any medical care shoud the cost of that medical care not be reimbursed by the health insurance provider. Further, I affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still be in force.

*This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any libality against personal losses.

 

*Today's Date:   (example: 10/28/1970)

 

Revision 10/19/2009

 

 

For the Student Medical Release and Permission Form please click here!