Haysville United Methodist Church Youth

Emergency Information and Waiver

 

Participants Name:_______________________________________ Home phone: ______________________________________
Birth Date: ________________________  Address: _______________________________________________________________
City/State/Zip: ______________________________________________________ Soc Sec #: ______________________________
                                                                                                                                              (Only if no insurance card)
 

IF MINOR: I/We the signed below give permission for our/my son/daughter to travel and participate with the Haysville United Methodist Church Youth Program in addition to understanding the implied intent of the liability statement below.
Liability Statement

IF ADULT: I will Travel and participate with the Haysville United Methodist Church Youth Program. I waive any claim for liability or damages, provided reasonable precautions have been observed, against Haysville UMC, Haysville, Kansas, any of its employees, or any person or persons transporting or assisting in this activity for any damage or injury which may be sustained by me during or in transit to this activity. I further agree not to ever sue, assert or otherwise maintain any claim or cause of action incurred in connection with the events included in the yearly schedule for Youth activities at HUMC.
X________________________________________________________________Date___________________

 

This information is confidential. Please complete all forms in their entirety, PRINTING LEGIBLY.
Name Father (if Minor) ________________________________ Name Mother (if Minor)___________________________________
Employer __________________________________________                                    ___________________________________    
Home Phone _______________________________________                                     ___________________________________
Work Phone ________________________________________                                    ___________________________________
 

Emergency Contact _______________________________________________________________________________________

Relationship: ________________________________________ Phone #: ____________________________________________
 
Last Tetanus: _____________________
 
Medication currently taking or carrying: _________________________________________________________________________
Dosage: _______________________________________________ Frequency: ________________________________________
Medication currently taking or carrying: _________________________________________________________________________
Dosage: _______________________________________________ Frequency: ________________________________________
Medication currently taking or carrying: _________________________________________________________________________
Dosage: _______________________________________________ Frequency: ________________________________________
Allergies (if none, state “none”) ______________________________________________________________________________
______________________________________________________________________________________________________
 
Physician: __________________________________________
Insurance Co.: ______________________________________  Policy Holder: ________________________________________  Policy #: ___________________________________________  Group #:____________________________________________
 

PLEASE ATTACH A COPY OF YOUR INSURANCE CARD