Teens (9th - 12th Grades) Youth Program Health Form

1

INFORMATION & PERMISSION FORM “TEENS” YOUTH PROGRAM (9th-12th Graders) Ketron Memorial United Methodist Church August 1, 2008 – August 31, 2009 Youth’s Name _____________________________________________ Birth Date _________________ Address ____________________________________________________________________________ City _________________________________________ State __________________ Zip ____________ Home Phone ________________________________ Youth’s Cell Phone ________________________ Youth’s E-mail _______________________________________________________________________ Age ________________________ Grade _______________________ Gender ____________________ EMERGENCY CONTACT PERSON: Parent/Guardian Name _________________________________________________________________ Address (if different from student) _______________________________________________________ City _______________________________________ State ___________________ Zip _____________ Home Phone ________________________________ E-Mail __________________________________ Father’s Cell Phone __________________________ Mother’s Cell Phone _______________________ Place of Work ________________________________________ Work Phone ____________________ ALTERNATE EMERGENCY CONTACT PERSON: Please designate an alternate contact person in case parent/guardian cannot be reached in the event of an emergency. Name _______________________________________________ Relationship ____________________ Address ____________________________________________________________________________ City ______________________________________ State ___________________ Zip ______________ Home Phone _________________________________ Cell Phone ______________________________ Place of Work _______________________________________ Work Phone _____________________ INSURANCE: If you have medical insurance, your carrier will be billed for medical charges in case of illness or injury while your child is at a “TEENS” Youth Program activity. Please attach a copy of the front and back of your insurance card.

2 Do you have health insurance? Yes __________________________ No ________________________ Name of Insurance Company ____________________________________________________________ Policy # _________________________________________ Group # ____________________________ Name on the policy ___________________________________________________________________ HEALTH HISTORY: List any pre-existing or present medical conditions: __________________________________________ ___________________________________________________________________________________ _ ___________________________________________________________________________________ _ Name and dosage of any medications that student must take: ___________________________________ ___________________________________________________________________________________ _ ___________________________________________________________________________________ _ List any allergies that student has, including allergies to medications: ____________________________ ___________________________________________________________________________________ _ ___________________________________________________________________________________ _ Please check any conditions that apply to your youth: □ ADHD

□ Asthma □ Diabetes □ Epilepsy □ Frequent Stomach Upsets □ Hay Fever

□ Heart Condition □ Nervous Disorders □ Physical Handicaps □ Severe Menstrual Cramps □ Other Conditions

Please give details of previously listed conditions, including treatment given: _____________________ ___________________________________________________________________________________ _ ___________________________________________________________________________________ _

3 Immunizations up to date? Yes___________________________ No ____________________________ Date of Last Tetanus Shot ______________________________ Contact Lenses? __________________

List activity restrictions we need to be aware of: ___________________________________________ ___________________________________________________________________________________ _ ___________________________________________________________________________________ _ Height __________________________ Weight _________________________ Family Doctor ___________________________________________ Phone _____________________ Location of Doctor ___________________________________________________________________ MEDICAL AND LIABILITY RELEASE: I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary. I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. Coverage by Ketron Memorial United Methodist Church will apply if my child is injured while in one of the church-owned vehicles, or if my child is injured while on the premises of the church building. Injuries incurred as a result of participation in sporting events are exempt in this policy. I understand that all ordinary safety precautions will be taken at all times by Ketron Memorial United Methodist Church’s Youth Program and its agents during all events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Ketron Memorial United Methodist Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. Parent/Guardian Signature ______________________________________________________________ Date _______________________________________________________________________________ TRANSPORTATION RELEASE: I give my permission to the bearer of this letter to transport my child to the program events sponsored by Ketron Memorial United Methodist Church of Kingsport TN, for all programs that take place within Kingsport TN and immediate surrounding areas. My child is allowed to travel out of Kingsport with the Youth Program when I have been informed of the specific destination, duration of the trip, and intended event ahead of time. Youth will not be allowed to travel with anyone that has not been authorized in writing by the parent/guardian. In the event that I cannot transport my child to and from the church for meetings or

4 special activities, I give permission to allow the following persons to transport my child for me. Appropriate identification may be asked for if adult leaders do not recognize a person bringing or picking up a youth at the church. Name ______________________________________________ Relationship _____________________ Name ______________________________________________ Relationship _____________________ Name ______________________________________________ Relationship _____________________ My child has permission to arrive or depart from the “TEENS” Youth Program meetings or special activities by walking or bike riding to and from the church. I also give my permission for my child to leave the Youth Program meetings and special activities before the end of the event. Additionally, I understand that by leaving, I release Ketron Memorial United Methodist Church, and the leaders of the event from liability for any accident that may occur while not present at the Youth Program meetings or special activities. Parent/Guardian Signature _____________________________________________________________ Date _______________________________________________________________________________ My youth, __________________________, is allowed to drive another youth(s) in his/her own vehicle during a youth sponsored event, when the youth leader or volunteers give consent. Please name who he/she can transport: _______________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ _ My youth, _________________________, is allowed to ride with a youth driver in their vehicle during a youth sponsored event, when the youth leader or volunteers give consent. Please name who he/she can ride with: __________________________________________________________________ ___________________________________________________________________________________ _ __________________________________________________________________________________ My youth, __________________________, may not ride with anyone other than the adult leaders and volunteers of the youth group. Nor may he/she transport other youth in his/her personal vehicle. Parent/Guardian Signature ______________________________________________________________ Date _______________________________________________________________________________ PUBLICITY AUTHORIZATION: I give permission for photographs taken of my child or me to be used for Ketron Memorial United Methodist Church’s youth program ministries’ publicity, printed or electronic. Parent/Guardian Signature ______________________________________________________________

5 Date _______________________________________________________________________________