Davidson United Methodist Medical Liability Form

We realize that information contained in this form is sensitive and personal. Only paid adult staff and adult volunteers working directly with the participant named on this form will have access to this information. The more fully the form is completed, the better we will be able to meet individual needs.
 
 
Please select one option.
 
 
 
 
Emergency Contact Information

 
 
 
 
 
 
Allergies and Medications

Please select all that apply.
 
 
Please select one option.
Please select all that apply.
 
Please select one option.
Please select all that apply.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Please select one option.
NOTE: for ages newborn to grade 8, ALL medications (prescriptions and OTC) MUST be administered by adult leadership.
Chronic Health Concerns

Please select all that apply.
Please select all that apply.
 
 
Special Needs/Disability Awareness:

Please select all that apply.
Please select all that apply.
 
Diet

Please select all that apply.
Please select all that apply.
 
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).
Please select all that apply.
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 to Karen Payne (kpayne@davidsonumc.org), please do so within 3 days of submitting this medical form. 






 
 

Description

We realize that information contained in this form is sensitive and personal. Only paid adult staff and adult volunteers working directly with the participant named on this form will have access to this information. The more fully the form is completed, the better we will be able to meet individual needs.