Medical Release Form

Parents and Guardians of Youth,

Please complete the general release, medical authorization and permission statement below each year for your youth.

General Release, Medical Authorization and Permission Statement

The undersigned parent(s) and/or guardian(s) of the youth named in the completed form below, in consideration of said child participating in any activity of the St. Mark’s United Methodist Church, individually and as parent(s) and/or legal guardian(s) do hereby generally release and covenant to hold harmless the St. Mark’s United Methodist Church and the duly authorized counselors, leaders, and approved assistants to the counselors and leaders of the activity from any action, cause or action, suits, damages, judgments, executions, claims and demands whatsoever, which the undersigned now have or may acquire by reason of any matter, cause or thing, and hold this agreement to terminate upon the above-listed child’s ceasing participating as a member of the activity.

Medical Authorization

Furthermore, the undersigned parent(s) and/or legal guardian(s) authorize St. Mark’s United Methodist Church and/or the United Methodist Youth Fellowship of the St. Mark’s United Methodist Church by its duly authorized counselors, leaders, and approved assistants to the counselors and leaders of the fellowship to consent to reasonable and necessary medical care and to administer common, necessary medications including-but not limited to-acetaminophen (“Tylenol”), diphenhydramine (“Benadryl”), and ibuprofen (“Motrin”), as may be required for the above-listed child while participating in program and fellowships sponsored by the St. Mark’s United Methodist Church and/or the United Methodist Youth Fellowship of the St. Mark’s United Methodist Church.

Emergency and Medical Release Form
(food, insects, medicine, etc.)
(strenght and dose of prescribed and over the counter medications)
By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not check the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.
Clear Signature