RISE YOUTH MINISTRY

PARENTAL CONSENT/PERMISSION FORM

By my signature below, I the parent or legal guardian of child identified herin, give my consent for ____________________________
to participate in children and youth activities, outings and other trips sanctioned or sponsored by First United Methodist Church,
McAllen, TX (McFirst). I understand this includes, but is not limited to transportation for activities away from the physical premises
of McFirst. I further understand that transportation will be provided as per the Child/Youth/Adult Saftery Policy of McFirst, as may
be amended from time to time. I also authorize staff and chaperones to authorize any and all medical treatement necessary for the
protection of the helath and well being of my aftorementioned child. This consent shall be deemed in effect for the remainder of
2012 and all of 2013 from the date signed, unless revoked or otherwise rescinded.

IDENTIFICATION AND GENERAL HEALTH INOFRMATION

Childs full name: _______________________________________________ First name child goes by: ________________
Addres: _____________________________________________________________ (CITY, STATE, ZIP)
q Male q Female Date of Birth: _____________________ Height: ______________ Weight: _____________
Medications: _________________________________________________________________________________________
Allergies: ____________________________________________________________________________________________
Special needs or concerns: ______________________________________________________________________________
_____________________________________________________________________________________________________

MEDICAL INSURANCE INFORMATION

Name of Insured: _______________________________________
Group #: _______________________

Medical Insurance Provider: ___________________

Policy # _______________________ Insureds SSN: _____________________

Insurance Company Phone #: __________________________________

Fax or Email (if any): ___________________

Family Physician: ___________________________ Phone #: _________________ Area Hospital Preference: ___________

PERMISSION TO RECEIVE MEDICAL TREATMENT

I authorize EMS personnel and/or emergency physicians and other medical professionals or hospital staff to prived necessary
medical treatment to my child who is identified above.
Parent/Guardian Phone #: _______________________________ Mobile Phone #: ________________________________
Physical Address (if different from child): ____________________________________________________________________
Emergency Contact (not living with child): ________________________________ Relationship: ______________________
Emergency Contact Phone #: ___________________________
Emergency Contact Physical Address: _______________________________________________________________________

_______________________________________________
Signature of Parent Date Signed

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Signature of Notary Date Signed