Tween / Youth Ministry Permission Form                                                       1st United Methodist Church LaPorte

Participant Information:

Name

Birthdate

Gender

Phone

Email Address

Street Address

City

State

Zip

Name

Phone (Mobile)

Phone (Work)

Name

Phone (Mobile)

Phone (Work)

Name

Phone (Mobile)

Phone (Work)

Relation to child

Family Doctor

Phone

Medical Conditions

Allergies

Medications

I give permission to give non-prescription (i.e. Tylenol, Benadryl, throat lozenges) medication (circle one) Yes / No

Food Allergies

Food Restrictions

Insurance Company

Group #

Policy #

I give First United Methodist Church permission to use photos of my child for bulletin boards, newsletters, Facebook, or scrapbooks.

Parent / Guardian