Medical Release - Speedway UMC

Participant and Medical Release Form

This form is required for many activities and events sponsored by Speedway UMC and is helpful for keeping participants safe by having current medical and insurance information on hand in case of an emergency. In order to keep this information up-to-date, you will be expected to fill this form out at least once per year. We also ask that you contact us if you have any changes to your (or your child’s) personal, medical, or insurance information so we can update our records.

Participant Information

Full Legal Name of Participant *

First

Last

Name Participant Would Like to Be Called

First

Last

Gender *

Pronouns

Sex assigned at birth: *

Male
Female

Date of Birth *

Phone with area code *

Cell Phone *

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Please list any current medical conditions, allergies, etc. of the participant:

Participant's Physician Name: *

Participant's Physician Phone: *

Participant’s Legal Guardian Name (if minor):

First

Last

Participant’s Legal Guardian Phone (if minor):

Emergency Contact Information

Emergency Contact Name: *

First

Last

Emergency Contact Phone: *

Relationship to Participant: *

Medical Insurance Information

Participant Insurance Carrier: *

Participant Insurance Contact Number: *

Participant Insurance Policy #: *

Participant Insurance Group #: *

Policy Holder Name: *

First

Last

Policy Holder Phone: *

This release form pertains to ALL Speedway United Methodist Church sponsored activities unless otherwise specified here, in which it will only pertain to the activity or activities listed as follows:

This release form starts on the date signed below and is good for 12 months from that start date unless otherwise specified here in which release is only good through

Provide the name(s) of any person(s) you do not authorized to pick up your child from a Speedway UMC event. If any aforementioned individual is not legally allowed to pickup by court order, please provide documentation to the church office.

Participation Release Statement

I wish to participate/wish the child for whom I am legal guardian of to participate in the above activity scheduled by Speedway United Methodist Church. I am aware of any special dangers and risks inherent in participating in the above activity and/or riding in arranged church transportation, including physical injury, or other consequences arising or resulting from the above activity. I agree to assume and accept responsibility for such risks. I agree to assume and accept responsibility for any medical costs which may result from my participation or my child’s participation in the above activity.

In consideration of and part of a right to participate in the above activity, I hereby agree to indemnify, release and hold harmless Speedway United Methodist Church and it’s Trustees, officers, appointees, agents, and employees from any and all losses, costs, damages and expenses, including attorney’s fees, arising out of or resulting from any claim (including claims based in whole or in part upon allegations of negligent acts or omissions of any of the indemnified parties) by or on behalf of any person, for any personal injury, death or damage to property arising out of my participation or the participation of the child for whom I am legal guardian of in the above activity offered by Speedway United Methodist Church. I have read this release, indemnification and hold harmless agreement and understand its meaning.

As the signed of this document which describes you? *

Type your initials to indicate you have read and understand the Release Statement: *

By signing below, I consent to the terms of the release:

Clear Signature

Date Signed

Participant and Medical Release Form

Participant Information

Emergency Contact Information

Medical Insurance Information

Participation Release Statement

Speedway UMC

Worship Times

Casa de Dios

Child Care Ministry