Medical covenant form.pub

2011 COKER UNITED METHODIST CHURCH
AUTHORIZATION FOR EMERGENCY MEDICAL CARE
Youth’s Name:_______________________________________________________________________________________ M / F
E-Mail Address:________________________________________ Parent’s e-mail_________________________________________
DOB:_______________________________Age:______________________Grade:_____________T-Shirt size__________________
Address:____________________________________________Zip____________Home phone number:________________________
Father/Guardian’s Name:__________________________________________________DOB:__________/__________/__________
Work Phone:_____________________________________________Alt#________________________________________________
Mother/Guardian’s Name:_________________________________________________DOB:__________/__________/__________
Work Phone:_____________________________________________Alt#________________________________________________
Close Relative or Friend:_____________________________________Hm Phone:_________________Wk Phone:_______________

Any known allergies requiring special attention:_____________________________________________________________________

Medical history:______________________________________________________________________________________________
Date of last Tetanus shot:_______________________________________________________________________________________

Current medications, dosage & use:_______________________________________________________________________________
Physician:________________________________________________________Phone:______________________________________
Address:____________________________________________________________________________________________________
Dentist:__________________________________________________________Phone:_____________________________________
Address:____________________________________________________________________________________________________
Health Insurance Group:________________________________________________________Group#__________________________
Insurance Company Address:____________________________________________________Phone#__________________________
DOB of Primary Card Holder:__________/__________/__________ (hospital requirement for medical attention)
• I hereby give consent to any of the Coker UMC staff and/or volunteer staff to seek emergency medical treatment for my child(ren) named above in the event of an emergency and in my absence While understanding that all reasonable safety precautions will be observed, I understand the possibility of unforeseen hazards and the inherent possibility of risk. I voluntarily agree not to hold legally liable Coker UMC, any of its employees, volunteers, or other representatives associated with providing or arranging for emergency medical treatment for my child(ren).” • I herby grant permission for Coker United Methodist Church Adult Sponsors and Leaders to administer non-prescription, over- the-counter medication and prescription medication to the designated youth when such medication is brought in the original prescription container. Contains
Circle One
• I hereby grant permission for my child to participate in all of the activities of the church. • I hereby grant permission for my child to leave the church premises under the supervision of an adult for church related activities. • I hereby grant permission for my child’s picture to be taken by Coker UMC employees, volunteers, or other representatives associated with church events & activities on and off the church premises to be used in church newsletters, brochures, displays and web pages. • I hereby waive any claim against Coker United Methodist Church. COKER UNITED METHODIST CHURCH
FOR UMYF, SUNDAY SCHOOL, BIBLE STUDY, OUTINGS, & RETREATS 1. Have fun 2. Be at all events on time, stay for the duration of the event, don’t leave the designated areas for the event, and participate fully in all activities planned. 3. Respect the physical and emotional well being of other youth and adults by “doing unto them as you would have them do unto you.” 4. Respect the property of the places that we visit, the church property, and the property of other people. 5. Listen, respect, and follow the word of your adult counselors and leaders and report any injury or illness immediately to them. 6. Respect the health of your body and others by not possessing or using any kind of weed, tobacco, alcohol, pills, or other substances. Unless it is a prescription drug and written permission has been granted by parent or legal guardian. 7. Possession of or use of any fireworks, firearms, or other weapons is prohibited at any church related activity. 8. Do not engage in any inappropriate sexual behavior. You will not be with the opposite sex in the opposite sex’s room, when on 9. Always remember who you are in Christ, and act and dress accordingly. Clothe yourself with Christ. Remember you represent
NOTE: In the case of any misconduct, the adult leaders reserve the right to call parents and send youth home at the expense of the
parents. The signatures below indicate that all understand the program and commit to having the most positive experience.
________________________________________________________________Date________________________________________
Signature of youth
I hereby certify that I have read and fully understand all the permission I grant to Coker UMC and the Covenant of Conduct.
Furthermore I understand the permission I grant to administer over-the-counter and prescription medication.
________________________________________________________________Date________________________________________
Signature of parent or Guardian
231 E. North Loop Rd., San Antonio, TX 78216

Source: http://www.coker.org/clientimages/26373/deliasfiles/medical%20covenant%20form%202011.pdf