The purpose of this form is to provide information for College Hill United Methodist Church staff in the event of an emergency. As used in this authorization and release, the name College Hill United Methodist Church shall be understood to include, not by way of limitation, all paid staff and unpaid leaders, committees, boards, and membership. This release and authority shall be valid for any youth activity (including, but not limited to travel by car, plane, and other forms of transportation) in which my child participates unless revoked in writing prior to the date of that activity.

Please complete with as much detail as you can. 

(MISSION TRIP PARTICIPANTS- attach a copy of Insurance Card).

THIS FORM MAY BE USED FOR ENTIRE FAMILIES OR INDIVIDUALS. Please complete accordingly.

I understand that the CHUM staff and sponsors need to know pertinent information about the participant's mental and physical health. Therefore, anything that would jeopardize the participant's safety or the safety of others has been disclosed with the understanding that this information will be kept confidential except on a "need to know" basis.

I understand that if I have omitted vital information that could put the participants or others in danger and/or if their conduct becomes a detriment to the CHUM activity, that they may be sent home at guardian expense or guardians will be called to pick them up immediately.

I hereby give permission for a CHUM PASTOR, DIRECTOR, OR SPONSOR/LEADER to seek proper medical help in the case of an emergency, and, if needed, give the physician authority to hospitalize and/or order injections, anesthesia, or surgery in the course of securing proper treatment.

I agree that any pictures taken in the course of CHUM Activities, which includes photos and video of my child, may be used for publicity of that event on the College Hill UMC web page, social media platforms, and other pictorial formats.