Children & Youth Waiver

First United Methodist Church of Titusville
Children and Youth Waiver Form

Waiver MUST be filled out by legal guardian*
Online waiver for temporary period - Notarized waiver is needed for weekly pickups and programs

* Indicates required field

Current Date (Month/Day/Year) *

Student Information

Student Name *

First

Last

Select One *

Birth Month *

Birth Year *

School *

Grade Level *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Student Health History

Allergies *

Chronic or recurring illness or medical condition *

Dietary restrictions *

Current Medications (list prescription, Over the counter & herbal)

Medication & reason for taking *

Any other information you feel the leader/teachers should know in advance: *

Parent/Guardian Information

Must be filled out by legal parent/guardian of the child

Parent/Guardian Name *

First

Last

Phone Number *

Alt. Emergency Contact *

First

Last

Phone Number *

Parent/Guardian Email *

Waiver

FUMC is not responsible for the loss or theft of personal belongings.
Misconduct may result in transportation home from an activity. A dismissed for a disciplinary reason will not receive a refund of the activity fee.

I understand and authorize that my child's image may be photographed or filmed and used in video presentations, Children/youth ministry Facebook, and First United Methodist website.

My child can be photographed *

yes no

I hereby take the following action for my child, myself, my executors, administrators, heir, next of kin, successors and assigns: A) I waive, release, and discharge from any and all claims or liabilities for death or personal injury damages of any kind, which arise out of or relate to my child’s participation in FUMC’s activities, the following person, or entities: FUMC, it’s Senior Pastor and Associate Pastors, Elders, employees, volunteers, representatives, subcontractors and agents of any of the above: B) I agree not to sue any of the persons or entities mentioned above for any of the claims or liabilities that I have waived, released or discharged herein except in the case of gross negligence in the part of FUMC, FUMC’s staff or volunteers and: C) I indemnify and hold harmless the person or entities mentioned above from any claims made or liabilities assessed against them as a result of my child’s actions. I hereby assume the risks of my child participating in all FUMC ministries activities.

I hereby agree to all the above First United Methodist Waiver and Release Form Liability conditions. *

yes no

I confirm that I am a legal guardian of the Child listed *

yes no

Form of identification *

Max file size: 20MB

Comments *

Submit

For any problems contact Lauren at LPeterson@fumctitusville.com

Youth Director Email

Children's Director Email

First United Methodist Church of TitusvilleChildren and Youth Waiver Form

Student Information

Student Health History

Current Medications (list prescription, Over the counter & herbal)

Parent/Guardian Information​

Waiver

We Would Love to Have You Visit Soon!

First United Methodist Church of Titusville
Children and Youth Waiver Form

Parent/Guardian Information