
St. Matthews Universal Information, Consent & Standards Form
In order for youth to participate in youth ministry activities or trips, all fields on this form must be completed and all requested documents must be turned in to the appropriate department (i.e. Music Ministry, Youth Ministry, etc.)
Full Name of Youth
Grade/ Age
Date of Birth (MM/DD/YYYY)
Youth Cell Phone Number
Youth Home Phone Number
Youth Address
Mother/Legal Guardian Name
Mother/Legal Guardian Home Phone, Work Phone, Cell Phone, Fax Number
Mother/ Legal Guardian Email Address
Father/Legal Guardian Name
Father/Legal Guardian Home Phone, Work Phone, Cell Phone, Fax Number
Father/ Legal Guardian Email Address
Youth Medical Insurance Company
Insurance Group #/ Policy #
Insurance Billing Address
Emergency Contact Name & Phone Number, Relationship to Minor
Youth's Primary Physician/Physician Office Number
PLEASE EMAIL OR GIVE A COPY OF BOTH THE BACK & FRONT OF YOUR YOUTH'S MEDICAL INSURANCE TO THE APPROPRIATE DEPARTMENT GHan@StMatthewsUMC.org (UMYF, Youth Sunday School, Youth Mission & Service), NCappel@StMatthewsUMC.org (Youth Music)
Allergies or Medical Conditions	asthma allergies diabetes medications seizures reaction to medications other
In the following area please explain any of the checked boxes above or any further medical/illness information the youth team and physicians should be aware of. Please also explain any limitation for activity or if action of protection is required. If additional space is needed for explanation, please send an email to GHan@StMatthewsUMC.org (UMYF, Youth Mission & Youth Sunday School) or NCappel@StMatthewsUMC.org (Youth Music)
Consent for Participation - I/We, the undersigned, have legal custody of the youth named above, a minor, and have given our consent for him/her to attend and participate in all youth events organized by St. Matthew's UMC. I/We understand that there are inherent risks invovled in any ministry or athletic events, and I/we hereby release the Church, its pastors, employees, agents and volunteer workers from any and all liability for any injury, loss or damage to person or property that may occur during the course of my/our child's involvement.
Consent for Transportation - I/We give permission for the above named youth to be transported during St. Matthew's youth events. Transportation may be by Church van, private vehicle, or other conveyance. I understand that there will be supervision for each trip and that all passengers will be required to comply with church rules for travel. I also understand that the Church provides no insurance for transportation other than standard liability insurance coverage. I/we are responsible for transportation to and from any event, and this may be done by youth licensed to drive with my/our permission. I/we also agree to bring my/our youth home at my/our own expense should they become ill or if deemed necessary by a youth ministry team member.
Consent for Medical Treatment - In the event that the youth named above is injured and requires the attention of a doctor, I/we consent to the rendering of routine or emergency medical/dental care necessary to preserve the health of my/our youth, including diagnostic, medical and surgical treatment by authorized members of an outpatient, emergency or hospital staff or their designees, as may in their professional judgment be necessary. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person(s) free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/we also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the youth named above. I also authorize first aid to be administered as judged to be needed by ministry staff.
Consent for Photography - I/we give persmission for photographs or video of the above named youth to be taken during St. Matthew's Youth events. These images could be used in publications, multimedia presentations, online promotion for St. Matthew's (including St. Matthew's Website, Facebook, Flickr, etc.), print materials and archiving purposes. Web images will not identify the youth by name and all identifying markers will be removed).
St. Matthew's Youth Commnunity Standards	We will be respectful and welcoming to all youth and adults We will follow leader instructions and event schedules We will fully participate with the group activities - early youth departures require permission by a leader We will respect all property at church or other event locations We shall refrain from abusive malicious or offensive language We shall refrain from possession or use of alcohol drugs and tobacco we will refrain from fighting weapons fireworks lighters or explosives We shall refrain from offensive or immodest clothing We shall refrain from public displays of affection sexual misconduct or harassment Adults are to drive during ministry events as detailed in the SMUMC Child/Youth Protection Policy Males will not enter female sleeping quarters and females will not enter male sleeping quarters During designated free time Sr. High Youth will be in groups of at least three and Jr. High will be with leaders Use of mobile phones computers or media players is at the discretion of leaders Some events and trips require previous participation and demonstrated observance of community standards All of the above (once you have read through this list please choose this option)
By checking this box I/we agree to all of the terms and conditions stated throughout this consent form.
Please provide today's date, this form will not be considered completed without the date (MM/DD/YYYY)
Parent/Guardian Name
Parent/Guardian Name
Youth Name