PERMISSION SLIP FOR YOUTH ACTIVITIES SPONSORED BY
FIRST UNITED METHODIST CHURCH
22124 Garrison Street
Dearborn, Michigan 48124-2274
Phone: 313-563-5200




I give my permission for ______________________to attend the following event sponsored by the U.M.Y.F. (United Methodist Youth Fellowship)

__________________________________________________________________

__________________________________________________________________
(List days, dates and name of event)


I hereby relieve the church and its agents from any responsibility or liability in case of injury. I also give my consent for emergency medical treatment, with the understanding that I shall be contacted as soon as possible. I also understand that myself or someone with legal guardian status will remain available by phone during the time the named youth is at the event.



Note: If you are new to the church, do not have a health form on file or your health information has changed, please complete the information below:

Any known allergies ______________________________________________________

Medication Now Being Taken _______________________________________________

Complete Health insurance Information _________________________________________

Birth Date of Youth __________________ Relationship to Youth __________________

Signature __________________

Date Signed __________________

Emergency Phone Number __________________

_________ Please initial here if health information already on file is correct.