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Authorization for Emergency Medical Treatment
Activity: ________________________________________________________________
Date of activity: _______________________________
In consideration of permission granted my child by Omaha First United Methodist Church to participate in the above trip with Church Youth Group, I release and discharge Omaha First United Methodist Church, the youth leaders and participating sponsors from all claims, demands, actions, judgments, and executions which the undersigned’s heir, executors, administrators, or assigns may have, or claim to have, against Omaha First United Methodist Church, youth leaders and participating sponsors or their successors or assigns, for all personal injuries known or unknown and injuries to property, real or personal, caused by or arising out of the activity noted above.
Further, as a parent of _____________________________________, a minor, I hereby give my consent, in the event that all reasonable attempts to contact me (enter phone numbers) ______________________ (home) or __________________________ (cell) or ____________________________ (work) have been unsuccessful, for youth leaders or participating sponsors in whose care the minor child has been entrusted to consent to any treatment for common illness, x-ray examinations, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered to the minor child by any physician or dentist licensed to practice in the state in which my minor child may be located.
I have read and agree with the Omaha First United Methodist Church Code of Conduct on the reverse side of this sheet, as my youth is a minor and, therefore, not entitled to consume or possess alcoholic beverages (or any other controlled substance). I, by my signature on this document, agree to have ____________________________________ (youth’s name) sent home by the fastest method possible in the event he/she behaves in a way not conducive to their agreement with the United Methodist Church’s Code of Conduct as seen by the youth leaders and participating sponsors. My signature, furthermore, represents agreement to pay for any charges incurred in procuring transportation home.
I, the undersigned, have read this Release and Authorization for Medical Treatment and Code of Conduct form and understand all its terms. I execute it voluntarily and with full knowledge of its significance.
______________________________________ _____________________________
Parent/Guardian Signature Date Signed
________________________________________________________________________
Medical Insurance Carrier and Policy/Group #
_______________________________________ ______________________________
Emergency Contact/Relationship Phone Number
Omaha First United Methodist Church
Youth involved in this program (trips, missions, worship, activities, games etc.) are representing not only themselves but their families and their churches. It is the intent of this code of conduct to state the proper behavior and conduct which is expected of all youth and adults.
Each youth and adult must treat each other as a Child of God; a person of value, worth, dignity and who is special to God. No one has the right to treat anyone else as if they do not matter.
As member s of the body of the church, we will also obey the laws of the community regarding tobacco, alcohol, fire arms, drugs, property damage, infliction of bodily harm and show respect by following the directions of adult leaders.
Action will be taken based on severity of the offense. Minor infractions will first receive a warning, then a call to parents. Major infractions will result in immediate parental or proper authority contact.
2/2004