2022 St. Andrew UMC Student Release and Waiver

Student 1 Name

Student 2 Name

Student 3 Name

Student 4 Name

Address

Parent/Guardian Name(s)

Insurance Information

Insurance Company

Insurance Number

Physician Name

Emergency Contact (this will probably be parent/guardian)

Name #1 Emergency Contact

Phone #1 Emergency Contact Phone

Name #2 Emergency Contact

Phone #2 Emergency Contact

Medical Concerns

Allergies (list severity) or medical concerns we should be aware of

Permissions

I authorize St. Andrew UMC and its staff and volunteers to seek medical care on my child's behalf if I cannot be reached within any medically necessary time-frame. Please initial here to give your permission.

I give permission for the staff and volunteers (21 years of age or older) to transport my child as is necessary for the sponsored event/s. Please initial here to give your permission.

Please type your full name here as an electronic signature

Today's date

Description

Please fill out this form and click submit.

2022 St. Andrew UMC Student Release and Waiver

Description

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