2023-2024 St. Andrew UMC Family Ministries Release and Waiver

Student 1 Name

Student 2 Name

Student 3 Name

Student 4 Name

Student 5 Name

Primary Address

Parent/Guardian Name(s)

Insurance Information

Insurance Company

Insurance Number

Physician Name

Physician Phone Number

Emergency Contacts (this can be another parent/guardian)

Emergency Contact #1 Name

Emergency Contact #1 Phone

Emergency Contact #2 Name

Emergency Contact #2 Phone

Medical Concerns

Allergies (list severity & any emergency action procedures) 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 all sections in the Release & Waiver for Family Ministries. This form allows for your child(ren) to participate in events where you as a parent/guardian are not present or for events off St. Andrew property. If you have any questions/concerns please contact one of the Family Ministries directors who will assist.

Director of Children's Ministry
Danielle Buckley
(765)497-7755 ext. 4
danielle@andrew-umc.org

Director of Student & Young Adult Ministry
Janee LaFuze
(765)497-7755 ext. 114
janee@andrew-umc.org

2023-2024 St. Andrew UMC Family Ministries Release and Waiver

Description

Please Fix the Following