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INFORMATION & PERMISSION FORM

“TWEENS” YOUTH PROGRAM (6th-8th 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 the 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 the case of illness or
injury while your child is at a “TWEENS” Youth Program activity. Please attach a copy of the front
and back of your insurance card.
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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: __________________________________________

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Name and dosage of any medications that student must take: __________________________________

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List any allergies that student has, including allergies to medications: ____________________________

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Please check any conditions that apply to your youth:

□ ADHD □ Heart Condition
□ Asthma □ Nervous Disorders
□ Diabetes □ Physical Handicaps
□ Epilepsy □ Severe Menstrual Cramps
□ Frequent Stomach Upsets □ Other Conditions
□ Hay Fever
Please give details of previously listed conditions, including treatment given: _____________________

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Immunizations up to date? Yes ___________________________ No ___________________________

Date of Last Tetanus Shot ______________________________ Contact Lenses? __________________

List activity restrictions we need to be aware of: ___________________________________________

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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 adult leaders of the “TWEENS” Youth Program to transport my child to
the meetings and program events sponsored by Ketron Memorial United Methodist Church of Kingsport
TN, for all programs that take place within Kingsport TN and the 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.
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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
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 “TWEENS” 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 events.

Parent/Guardian Signature ______________________________________________________________

Date _______________________________________________________________________________

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: __________________________________________________________________

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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 ______________________________________________________________

Date _______________________________________________________________________________