2019-2020 Student Ministry
Activity Permission, Medical and Photo/Press
Release Form

If you have more than one student please fill out the form for each student. After submitting, refresh the page and fill the form out again.

Student Information
Student Name *
Student Name
Date of Birth *
Date of Birth
Parent(s) / Guardian(s)
Parent/Guardian *
Parent/Guardian
Phone *
Phone
Parent/ Guardian
Parent/ Guardian
Phone
Phone
Address *
Address
Emergency Contact (Not a Parent or Guardian) *
Emergency Contact (Not a Parent or Guardian)
Phone *
Phone
Insurance Information
Policy Holder Date of Birth *
Policy Holder Date of Birth
Policy Holder Phone Number *
Policy Holder Phone Number
Insurance Verification Phone Number *
Insurance Verification Phone Number
I give permission for my child (named above) to participate in Prosper UMC youth ministry events for the 2019-2020 school year. I understand the nature and risk level of activity in which this youth will be a participant. I also give permission for the participant to ride in Prosper UMC owned, rented or volunteered vehicles used for this activity. I authorize any staff member or chaperone of Prosper UMC to administer necessary first aid and/or procure necessary medical aid at or from any licensed medical facility or physician’s office. I also authorize the selected physician(s) and/or medical facility to provide such medical treatment as necessary for the above participant.
I understand that promotional pictures (individual and group) have been/will be taken during these events. I give permission for my student’s picture to be used for promotional materials (newsletter, web page, promotional signs, Facebook, etc.) in highlighting the event. I also authorize any publication, broadcast or other use of my student’s name, photograph, likeness, image, voice and biography in any and all media, publications, advertising, and publicity arising out of any activity associated with the program without further compensation and agree that all such materials are the sole property of Prosper United Methodist Church.