Manchaca UMC

MUMC Youth Medical Release Form

Personal Information

Please fill out all fields as accurately as possible.


for sleeping arrangement purposes

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Medical Information

Please fill out all fields as accurately as possible. 

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Prescription Card*

If yes to having a Prescription Card

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Medical History

Please fill out all fields as accurately as possible.


Does your child experience and/or is being treated for any of the following:

If you check other, please explain in the next box.

Does your child suffer from Asthma? *

Does your child use a rescue inhaler?*

if yes, they will be required to have their inhaler at MUMC Youth Group activities.

Does your youth wear:

For your youth's safety and our knowledge, rate their swimming skill level.*

Safety Rules Agreement

For your information, we expect each youth to conform to these rules and conduct:

  • No possession or use of alcohol, illegal drugs, or tobacco.
  • No fighting, weapons, fireworks, lighters, or explosives.
  • No offensive or immodest clothing.
  • No energy drinks.
  • Use of seatbelts is required when in moving vehicles.
  • Participation with the group is expected. 
  • Respect property.
  • Respect one another, staff, and adult leaders.
  • Respect and comply with event schedules.

Youth who fail to comply with these expectations may be sent home at their parents' expense. 

Youth Signature

I, the youth, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth group activities. I agree to abide by the stated personal limitations and rules of conduct.

I acknowledge that my name, entered above, acts as my signature for this document.

Parental/Guardian Permission

The Above-named youth has my permission to attend all youth activities sponsored by Manchaca United Methodist Church (hereinafter the "Church") from today until February 28, 2019. 

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff from any liability against personal losses of above-named youth.

I/we, the undersigned, have legal custody of the above-named youth, a minor, and have given my/our consent for him/her to attend events being organized by the Church. I/we understand that there are inherent risks involved in any ministry or athletic event, 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 youth's involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event of treatment being deemed required from a physician and/or hospital personnel designated by the church, I/we agree to hold such person 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 above-named youth. I/we also agree to bring my/our youth home at my/our expense should they become ill or if deemed necessary by the youth ministries staff member. 

Parent/Guardian Signature

I acknowledge that my name, entered above, acts as my signature for this document.