Youth Group Medical Release and Covenant Form

Faith United Methodist Church
Youth Group Activities

Medical Release/Covenant Form


Name: __________________________________________________________________________________________
(Last)                                                                    (First)                                                  (Middle)

Date of Birth: ___/___/___     Age: ______   Grade _______


Address: ________________________________________________________________________________________

(Street)                                                               (City)                                       (Zip Code)

Phone Contacts:           Home __________________                              Work ___________________
Cell    __________________                              Other ___________________

Emergency Contact:

Name: ___________________________________ Daytime Phone ______________  Evening Phone______________
(Parent, Legal Guardian)

Address of above name: ___________________________________________________________________________

(Street)                          (City)                                       (State)                                     (Zip)




Allergies/special health concerns/needs:


Medication(s) you can NOT take: ______________________________________________________________________

Medication(s) being taken: ___________________________________________________________________________

Special Dietary Needs: ______________________________________________________________________________



Insurance Information

Insurance Company: ____________________________________________Phone: _____________________________
Address: _________________________________________________________________________________________

(Street)                                                  (City)                                       (State)                                     (Zip)

Policy #: _________________________________ Group #: ________________________________________________

Doctor’s Name: _______________________________________________ Phone: ______________________________

Address: _________________________________________________________________________________________

(Street)                                                  (City)                                       (State)                                     (Zip)


In the event of an emergency or non-emergency situation in which medical treatment is required as a result of participation in the Youth Group, every reasonable effort will be made to contact the persons listed.  If unsuccessful in contacting the persons listed, consent/permission is given for treatment by competent medical personnel.


Further, and unless specified otherwise, consent/permission is hereby given to assigned Youth Group Director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery (under recommendation of qualified medical personnel).


I, the undersigned, who by law may do so, authorize the administration of emergency medical treatment to s/he who is the subject of this form.  I understand that all reasonable safety precautions will be taken at all times by the Youth Group Director or its agent liable for any accident, injury or disease incurred by the subject of this form.  I understand that in the event that medical intervention is needed every attempt will be made to contact the person(s) listed immediately.


I, the undersigned, also authorize the participation of the subject of this form in all activities relating to Youth Group Activities.  I understand that this form is effective for every Youth Group event/meeting.  I understand that it is my responsibility to provide any updates to this information to Faith United Methodist Church during my/my child’s participation throughout my participation.  We, the guardian and the participant, also give Faith United Methodist Church permission to use the participant’s image in any publication materials that might be used to promote the ministry in the future.


Signature of Parent/Guardian)   _________________________________________________
Date _____________________________________________



Participant Behavior Covenant

(*to be signed by both youth and adult participants)


As representative of Christ and His Church, we, the participants in the Youth Group, take very seriously our responsibility to care for one another.  This covenant represents our affirmation of our concern and well being of the total community.   We covenant with each other to insure the safety of all, to make our time together most meaningful, and to care for the facility which we share.


In addition to our general concern for our community, we agree specifically to:

  • I will prayerfully prepare for youth group activities.
  • I will use language, behavior, and attitudes which are consistent with the Christian Faith.
  • I will observe all rules and curfews.
  • I will not use tobacco products, alcohol, or other illegal substances.
  • I will respect the person, equipment and property of others.
  • I will observe the “Lights Out” policy.
  • I will not enter the room of someone of the opposite gender.
  • I will encourage others to follow these rules and guidelines by holding my peers accountable.
  • I promise when the Youth Group Activity is over I will share my experience with others.


This covenant is made between each person and the whole group.  I understand that if I break the covenant and if the brokenness cannot be reconciled, that I may be sent home at my own expense.




Youth                                                   Date



Parent/Legal Guardian                          Date



Youth Group Director                            Date