Youth and Children’s Ministry Medical / Liability Release Form

A medical and liability release for events at St Paul United Methodist Church, specifically for children’s and youth events, is an important aspect of ensuring the safety and well-being of your student. You are required to select the event from the provided drop-down menu for which you are completing the medical and liability release form. It is crucial to have a copy of both the front and back of your student’s medical insurance card ready as you will be asked to upload it during the process. Once you submit the form, you will be guided to a page where you can electronically sign the consent. It is essential to thoroughly read the consent before signing it, as it outlines the necessary terms and conditions. Rest assured, a copy of the signed form will be emailed to you for your records. Your cooperation in completing this process is greatly appreciated as it contributes to maintaining a safe and secure environment for all participants.

Choose Youth or Children's Event(Required)

Participant Information

Because information is unique to individuals, a separate form is required for each participant of the same family.

Student's Name(Required)

First Last Suffix

If necessary, SUFFIX is Jr, Sr, II, III, etc.

Address(Required)

Street Address City State ZIP Code

Date of Birth(Required)

Parent / Guardian Information

Name of Parent / Guardian Completing this Form(Required)

First Last Suffix

This person will be required to electronically sign this form when completed. If necessary, SUFFIX is Jr, Sr, II, III, etc.

Cell Phone of Parent / Guardian Completing this Form(Required)

Work Phone of Parent / Guardian Completing this Form(Required)

Email of Parent / Guardian Completing this Form(Required)

Enter Email Confirm Email

Completed and signed form will be emailed to this address after signed by this person.

Name of Other Parent / Emergency Contact(Required)

First Last Suffix

If necessary, SUFFIX is Jr, Sr, II, III, etc.

Cell Phone of Other Parent / Emergency Contact(Required)

Work Number of Other Parent / Emergency Contact(Required)

Health Insurance / Medical Information

Physician(Required)

First Last

Physician's Phone(Required)

Medical Insurance Company(Required)

Group Number(Required)

Policy Number(Required)

Picture of the Front and Back on Medical Card(Required)

Drop files here or

Max. file size: 192 MB.

List and Allergies, Recent Illnesses or Injuries, Current Medications, or Other Health Information(Required)

If none, type “NONE”

Estimated Date of Last Tetanus Booster(Required)