Davidson United Methodist Medical Liability Form

Participant's Name

Date of Birth:

Gender

Email of Parent/Participant:

This address will receive a confirmation email

Best Contact Number:

Address

Emergency Contact Information

Emergency Contact 1:

Relationship:

Best Contact Number:

Emergency Contact 2:

Relationship:

Best Contact Number:

Allergies and Medications

Does the Participant have any known allergies?

Yes has allergies No, does not have any allergies

Participant has the following allergies (include all allergies, including food, medication, insect, latex, bee stings, seasonal, etc)

Describe the allergic reaction and what is done to manage it:

Participant carries an Epi Pen

Other:

If administering an OTC medication, my child/youth should receive:

Does participant take any medications on a regular basis?

Yes takes medication on a regular basis No, does not take medication on a regular basis

Participant takes the following medication on a regular basis. Name of Medication 1:

Reason for taking:

Dose:

Time of day, if applicable:

Name of Medication 2:

Reason for taking:

Dose:

Time of day, if applicable:

Name of Medication 3:

Reason for taking:

Dose:

Time of day, if applicable:

Name of Medication 4:

Reason for taking:

Dose:

Time of day, if applicable:

Youth in grades 9-12 please select one:

NOTE: for ages newborn to grade 8, ALL medications (prescriptions and OTC) MUST be administered by adult leadership.

Chronic Health Concerns

Does participant have any chronic health concerns and is capable of full participation?

Yes, has chronic health concerns No, does not have chronic health concerns

Other:

Provide detailed supportive care for each item checked.

Special Needs/Disability Awareness:

Does participant have any special needs and is capable of full participation?

Yes, has special needs/disability No, does not have any special needs/disability

Particpant has the following diagnosed special needs (check all that apply) ADD ADD/ADHD Autism Down's Syndrome Bi-polar disorder Behavioral disability Depression Learning Disability Patient Care Assistant (PCA) at school and/or at home

Provide detailed supportive care for each item checked.

Diet

Does participant have any known dietary restrictions?

Yes, has dietary restrictions No, does not have any dietary restrictions

Participant has the following dietary restrictions: Dairy Gluten Vegan Vegetarian

Other:

Other

Date of last tetanus shot

Photo Release

Davidson United Methodist Church (DUMC), its representatives, and employees may take photographs during DUMC-related activities. DUMC reserves the right to use those images, without compensation, in print and/or electronic communications for any lawful purpose, including publicity, illustration, advertising, and Web content (DUMC website, Facebook, Twitter, or Instagram).

I give permission for images of myself and/or my child/youth shared I DO NOT want images of myself and/or my child/youth shared

Medical & Liability Release Statement

My child/youth has permission to receive routine first aid care and the prescription and/or OTC medication(s) indicated on this form during their participation in DUMC activities. I understand that in the event medical intervention is needed, every attempt will be made to immediately contact the persons listed on this form. In the event the emergency contacts cannot be reached, I hereby give permission to the physician/dentist selected by the activity leaders to hospitalize, secure medical treatment, an injection, anesthesia, or surgery as deemed necessary. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Davidson United Methodist Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the participant.

THIS FORM WILL NOT BE VALID WITHOUT A FRONT & BACK COPY OF THE RESPONSIBLE PARTY'S INSURANCE CARD
This can be attached at the prompt below. Or, if submitting an email or hard copy send to:

Music Trips - Heidi Peters (hpeters@davidsonumc.org),
Youth Trips - Meredith Hinton (mhinton@davidsonumc.org),
Children Trips - Brittany Viehmann (bviehmann@davidsonumc.org), within 3 days.

Front of Insurance Card

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Back of Insurance Card

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Person completing this form:

Today's date:

Davidson United Methodist Medical Liability Form

Description

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