2015 FUMC Hurst Youth Missions: SAN ANTONIO Permission, Liability Waiver, and Medical Release Form

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1 Permission, Liability Waiver, and Medical Release Form I give permission to participate in activities of the Youth or Children s Division of the First United Methodist Church, Hurst, Texas for the dates below. I understand that such activities are those which are passed by the Church boards or Council and which are publicized in the church newspaper and/or bulletin. I support the Key Sponsor in acting as a responsible leader who is in touch with parent s as well as children s needs. I also realize that I may give special instructions and requests for any individual activity to the Youth Minister, Assistant Youth Director, Children s Minister, or Assistant Children s Director at ACTIVITY LIABILITY RELEASE: It is understood and agreed that the undersigned shall not bring or cause to be brought any action due to any accident or personal injury to my child or property damage that might result from my child s participation in any church sponsored activity, on or off campus, whether under the direct supervision of the church, its staff, adult youth, children s leaders, parents or other church members. To restate, the undersigned agrees to accept full responsibility for my child s participation in any church related or sponsored activity and to hold harmless First United Methodist Church, Hurst, Texas, its staff, adult youth or children s leaders and other church members. PHOTO RELEASE (initial and circle one): (initial) I (circle) [authorize] [do not authorize] First United Methodist Church, Hurst, Texas to use photos/videos, and/or other likenesses of myself and/or my child or the child for whom I have legal guardianship for any promotional materials regarding First United Methodist Church, Hurst, Texas, programs, facilities, or services. Such likenesses will not be sold to other parties. Promotional materials bearing these likenesses may be distributed for free to the public and posted on the church s website and social media outlets. First United Methodist Church, Hurst, Texas reserves the right to use any photo/video or likeness for a time period beginning when this form is signed and ending upon written request of participant, parent or legal guardian. For details about the church s use of photos and social media, consult the MinistrySafe Policy Manual which can be found at MEDICAL RELEASE: I do give my permission for to be administered medical aid by a physician or hospital staff if the need arises. I assume the responsibility for passing all communication concerning each activity to the parents of any visitor brought by my child or family. Activity: San Antonio Youth Mission Trip Dates: June 28 July 3, 2015 Student s Name: DOB: Grade in Fall 2015: Address: City, St, Zip: Student s Student s Phone: 1 st Parent/Guardian: 2 nd Parent/Guardian: Phone 1: home/work/cell Phone 2: home/work/cell 1: 2: Emergency Contact Name (Besides Parent): Emergency Contact Phone: Doctor Name: Doctor Phone: Insurance Company: Group #: Signature of Parent or Guardian: Date: *Please list any allergies, dietary restrictions, physical conditions, and/or current medications on the next page. First United Methodist Church of Hurst

2 Student Medical Information Form Please describe any allergies, dietary restrictions, physical conditions, or other pertinent medical information that church staff, designated volunteers, and/or medical personnel should be aware of: My student takes the following prescription and over the counter medications*: Medication (please also describe its appearance) Dosage Frequency (when should it be given) When packing medications for a trip, please send enough to cover the dosage and frequency requirements for the entire duration of the trip. Please make sure all medications are in clearly labeled original packaging with dosage and frequency information included. Place all medications in a zip-lock baggie with your student s name written clearly on the outside and when you check-in on the day of the trip, give the baggie to the designated parent who will administer your student s medications at the appropriate times while on the trip. The church s MinistrySafe policy requires that an adult administer all medications on overnight trips. If you have privacy concerns, please contact Rev. Matt Ybañez. *It is very strongly suggested that you consult your prescribing physician before deciding whether to skip any regularly prescribed medications during any youth trip. My student may take the following over the counter medications according to the dosage instructions provided by the manufacturer: Acetaminophen Benadryl Ibuprofen Hydrocortisone Cream Pepto Bismol Benadryl Cream Parent or Guardian Signature: Date: First United Methodist Church of Hurst

3 POWER OF ATTORNEY I, the undersigned, hereby authorize First United Methodist Church, Hurst, and any medical or dental persons to allow the adult Representative of the Group First United Methodist Church of Hurst Youth Ministries to act in my stead and IN LOCO PARENTIS for my Child,, to make any and all arrangements that are appropriate and in the best interest of my Child, for my Child s personal care, or medical, surgical or dental care, and: To give CONSENT in my name and in the name of my Child to any and all types of MEDICAL TREATMENT or procedures, DENTAL TREATMENT or procedures or SURGICAL procedures for my Child; To give CONSENT in my name and in the name of my Child to the disclosure of any confidential or privileged communication or information related to the care of my Child; and To give CONSENT in my name and in the name of my Child to the signing of any and all RELEASE OF LIABILITY AND INDEMNITY AGREEMENTS, being aware that THESE AGREEMENTS DO RELEASE LEGAL RIGHTS on my behalf and on the behalf of my Child and to legally bind me for my Child. A photocopy or facsimile of this instrument shall be deemed an original for all purposes. This document shall be valid for the period of time (trip dates) Parent s Name (PRINT): Date: Parent s Signature: Address: Home Phone: Cell Phone: Print Name of Child: DOB: County of State of Sworn before me this day of, 2015 Notary Public My Commission Expires :

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5 MinistrySafe Considerations The information below is from our church s MinistrySafe Policy and is provided for your reference. The full policy may be found online at WORKER TO CHILD/STUDENT RATIOS This church is committed to providing adequate supervision in all ministries with Protected Persons. The Central Texas Conference recommends that the primary student leader be at least 5 years older than the oldest student. Main helpers should be 1 year post high school or equivalent and be 3 years older than the oldest student participant. For groups up to and including 30 students, there will be a minimum of 2 unrelated Workers supervising. For groups larger than 30 students, there will be a minimum of 3 unrelated Workers supervising. For every additional 15 students, 1 Worker will be required. If a Worker is out of ratio, it is his/her responsibility to immediately notify the program supervisor or the Student Director. This person will make a diligent effort to immediately bring the Worker to student ratio into compliance with this policy. The above ratios are MinistrySafe minimum recommendations. Where supervision is concerned, more is generally better. SLEEPING ARRANGEMENTS It is anticipated that certain ministry activities may occasionally require that overnight sleeping arrangements be made for Protected Persons and Workers (i.e. retreats, lock-ins, mission trips, etc.). In the event an activity requires sleeping arrangements, Workers will strictly observe the following rules: 1. The two unrelated adult rule must be followed. The two adult leaders present must have previously completed our church s application and screening process. 2. Overnight arrangements, including sleeping, bathing, and changing, must be submitted in writing to and approved by the Executive/Senior Pastor prior to the activity, and have signed approval of Parents/Guardians. It is recommended that this information be included in the permission slip for the event and signed by the Parents/Guardians. 3. As long as any Protected Persons are awake, two of the leaders must also be awake and monitoring Protected Persons to ensure safe behavior. 4. Appropriately modest sleeping attire must be worn by Workers and Protected Persons. 5. In the event of a sleepover on campus that involves males and females, males and females must sleep in separate rooms, properly supervised by leaders of the same gender. 6. Workers will monitor sleeping Protected Persons by periodically conducting visual bed checks to ensure that sleeping Protected Persons remain in designated sleeping places. During bed checks, Workers should never physically touch a child. 7. In the event that overnight arrangements do not include standard beds, each Worker and Protected Person will use single sleeping bags or blankets. In these instances, a one-person-to-one bag or blanket rule will be observed. NUDITY Workers should never be nude in the presence of Protected Persons. In the event there is a situation that may call for or contemplate the possibility of nudity (i.e. changing clothes during a pool party, weekend or overnight retreat, etc.), the Ministry Director will submit a plan for approval to his/her supervisor concerning arrangements for showering or changing clothes.

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