Emergency Medical Release Form-BUMS Ministry

Broadway United Methodist Church - 701 Broadway - Paducah, KY 42001

This form is effective through December 31, 2010.

 

I, ____________________________ do hereby give my permission for my child to participate in the Broadway United Methodist Student Ministry (BUMS) of Broadway United Methodist Church (BUMC).  It is my understanding that the staff and volunteers of the church will take all necessary precautions to ensure the safety of my child.  I do hereby release the church from any legal or financial obligation due to accident or injury to my child. 

Student’s Name __________________________________________________

Address _________________________________________________________

Name(s) of Parent(s)/Legal Guardian(s) ___________________________

Home Phone ______________________________

Business Phone ___________________________

Cell Phone _______________________________

Other Phone _____________________________

 

Alternate person to contact in case of emergency if parent cannot be reached:

Name __________________________________

Relationship ___________________________

Phone _______________________________

Other Phone _________________________

 

In the event my child has need of medical attention, I do hereby give my permission for the staff or volunteers of BUMC/BUMS to obtain such medical treatment as deemed necessary.  I understand that every effort will be made to contact me or my alternate contact person.

 

Insurance Information

(Please attach a copy of the front and back of your insurance card.) 

Parent Signature _________________________________Date ____________ Initial _____  I give permission for my child’s picture to be used on the website or for further marketing publication.

Medical History/known allergies to food, drugs, bee stings, etc __________________________________________________________

List all medications currently taking and what they are treating __________________________________________________________

Physician’s Name _____________________________ Phone _____________

Should the need arise for simple, over-the-counter medication, my child MAY BE GIVEN the following: ___ Aspirin ___Tylenol ___Ibuprofen

___Tums ___Pepto Bismal ___Cough medication ___Allergy medication ___Eye drops ___Other over the counter medication, specifically _________________________

Is there any other medical or other information which the staff or volunteers should be aware of? ________________________________