March 8th, 2015 3pm 5:45pm

Youth Group meets at the Massillon REC Center

No cost to attend!
Invite your friends!*
Proper swim attire is required!
Shoes & towels must be worn in common areas

*Ages 10-18

Massillon Rec Center

505 Erie St., N.
Massillon OH 44646
330-832-1621
www.massillonrecreation.com

First United Methodist church

Methodist Youth Group
Permission slip and Medical Release form

Event: Day at the Rec Center

Location: Massillon Rec Center 505 Erie St N, Massillon, OH 44646
Date: February 8, 2015
Time: 3:00pm 6:00 pm
Participants Name_______________________________________________
Street address___________________________________________________
City____________________ Zip Code______________________________
Current Grade_______________ Date of Birth _______________________
I hereby grant permission for my child to participate in the above activity of the First United
Methodist Church Youth Group. Should any problems arise concerning the behavior of my
child and he/she would be required to return home prior to the end of the activity, I will make
arrangements to pick him/her up.
I am responsible for any medical expenses.
Signed: _____________________________ Date: _________________________
(Parent/legal guardian)
Home phone: (____)__________________ Work Phone: (____)______________
Cell Phone: (_____) ____________________
Who will be picking your child up at First United Methodist Church if other than yourself?
Name____________________ Phone_________________

Participant name: _____________________________________________________________

Emergency Contacts:
1. Name:__________________________ Relationship to participant__________________
Day Phone: __________________ Night Phone: ______________________
2. Name:__________________________ Relationship to participant__________________
Day Phone: __________________ Night phone: ______________________
Medical/Health Information: Allergies, chronic illness, or other pertinent health history: ________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Current Medications to be taken during the event which will be kept by the leaders:

_____________________________________________________________________________
_______________________________________________________
Any other Information (special needs, concerns):

_____________________________________________________________________________
_____________________________________________________________________________
____________________________________________
Doctor: ______________________________Phone:________________________
Insurance ID# ______________________________Name on insurance card: _______________________

I give permission to the leaders of FUMC Youth to authorize emergency medical procedures for
my child. They may also transport my child to and from _______________________(hospital).
Parent/Guardian signature: _______________________________
EMERGENCY MEDICAL AUTHORIZAION
I give my consent for emergency medical treatment by a certified first aider. In the event that additional
treatment is needed, the staff of the Emergency room of the hospital listed above, or one closest to the event
location, has my permission.
Parent/Guardian Signature________________________________Date:___________________________
Address__________________________________________________________________________
Phone (home) _________________________Work (work) ____________________________
Hospitalization plan and Group No.:___________________________________________________________