Permission/Liability Release Form
Student Ministry
Aldersgate United Methodist Church
Student’s Name:  					  Address:  						 City:  		State:  	Zip:  	 Age:  	Birth Date:  		Home Phone:  		 

Activity Permission/Release of Liability
We, the undersigned Parents/Guardians, hereby authorize our son/daughter to participate in 2012/2013
Offsite Student Ministry Events. In the event of an emergency we understand that all will be done to contact us. However, if we cannot be reached, we give permission to the physician selected by the Director of Student Ministry and/or Adult Leader to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for our child. Therefore, we release Aldersgate UMC and its agents, staff or adult chaperones to any and all actions, claims, liabilities, losses, and costs arising from or in any way connected with any accident involving or affecting our child (and not attributable to the negligence of such agent, staff or chaperone) and occurring while enroute to, during and/or returning from this trip. To the best of my knowledge, our child is in good physical health. I also understand and have discussed the rules with our student concerning no possession and/or use of alcohol, tobacco or drugs during any event.

Parents’ Signature:                                                                                Date:                                     

Home Phone:  	Work Phone:  	

Cell Phone:  	Pager 	

In Case of Emergency Notify:  	Phone:  	

Family Physician:  	Phone:  	

Family Insurance Company:  	

Policy Number:  	

Allergies:  	

Medications:  	

My son/daughter has permission to use the following over-the-counter medications:

Other Medical and/or Notes:

(PLEASE USE BACK FOR ANY ADDITIONAL NOTES/COMMENTS)

Driving Instructions for my youth

Please check the line in which you deem appropriate

My youth may ride only with adults over the age of 21	 	

My youth may ride with adults and those whom I name	 	

Additional Comments: