EmailMe Form - 1st UMC Student Registration 2011-12

Student Name

First Last

Age *

Birthday *

MM / DD / YYYY

Grade (entering)

School *

Student Address (Primary) *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Student Address (Secondary, if applicable )

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Student Home Phone *

### - ### - ####

Cell Phone

### - ### - ####

Email

Father / Guardian Name *

First Last

Father / Guardian Cell Phone

### - ### - ####

Father / Guardian Email

Mother / Guardian Name *

First Last

Mother / Guardian Cell Phone

### - ### - ####

Mother / Guardian Email

Emergency Contact (other than parent / guardian)

First Last

Relationship

Phone

### - ### - ####

Special Notes

Please list who will be dropping off / picking up your student from church activities and any special circumstances or family status we should be aware of (siblings, illnesses, births, deaths).

Does the student have access to a Bible at home?

Yes

No

Please check the areas that you would like to volunteer with church activities this year.

Lead or help on Wed. night

Lead or help on Sat. night or Sunday morning

Chaperone Special Events / Retreats

Drive for church activities

Physician

Physician Office Phone

### - ### - ####

Dentist

Dentist Office Phone

### - ### - ####

Medical Insurance Co. & Policy No.

Allergies or other health concerns

Please list any allergies or other health concerns your student has that we should know about.

Permission to Participate in Church Activities

By entering my name above, the registered student has my permission to attend all church activities sponsored by First United Methodist Church from September 1, 2011- August 31, 2012. This consent form gives permission to seek whatever medical attention is deemed necessary, and releases First United Methodist Church and its staff of any liability against personal losses of named student. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by First United Methodist Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release First United Methodist Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our student’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we 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 First United Methodist Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our student home at my/our own expense should they become ill or if deemed necessary by the adult leaders.

Permission to Photograph

From time to time pictures are taken of various activities taking place during church activities. By entering my name above, I give permission for my student to be photographed.