Date: July 18, 2015

Location: One Cedar Point Drive

Sandusky, Ohio 44870
Time: Meet at the church at7am
Back at the church... 2:30am
Cost: Adults- $40.00
Students-$40.00
Bring: Sack lunch and extra money if
needed.
*Drink bands will be provided.

First United Methodist church

Methodist Youth Group
Permission slip and Medical Release form
Event: CEDAR POINT
Location: One Cedar Point Drive Sandusky, Ohio 44870
Date: July 18, 2015
Time: 7am - 2:30am
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.:___________________________________________________________