Adult Medical Release Form

Volunteer Name*

First Last

Volunteer Email*

Volunteer Phone Number*

Date of Birth*

Gender*

Fully Vaccinated for Covid-19?*

Yes
No
Prefer not to Answer

List All Allergies Below*

List All Medications Below*

Emergency Contact Information

Emergency Contact Name*

First Last

Emergency Contact Phone*

Emergency Contact Email*

Insurance Information

Medical Insurance Company*

If none, please note N/A.

Insurance ID Number

Group or Policy Number

AUTHORIZATIONS

AUTHORIZATION TO CONSENT TO TREATMENT AND RELEASE OF LIABILITY*

I hereby waive, release and covenant not to sue Pulaski Heights United Methodist Church and its officers, agents, employees, volunteers or activity chaperones from any and all negligence or fault which might proximately cause any claim, injury, death or liability resulting from my participation in church sponsored activities.

I further hereby authorize and direct that the sponsors for this event be authorized to consent to medical treatment by qualified and licensed medical practitioners in the event of a medical or dental emergency, which, in the opinion of the attending physician, should be administered.

By checking this box I agree to the above statement

Untitled*

YES. I grant you permission to use photos/videos of me on PHUMC's social media, website, bulletin boards, and /or newsletter.
NO. Please do NOT use any photos/videos of me.

From time to time we take pictures or record video during phyouth activities. We would like your permission to use these pictures on our website, our social media, in our newsletter. We will not reference you by name or provide any specific information regarding your child. We also will never sell these pictures; we will use them exclusively for Pulaski Heights UMC purposes. Please take a moment to let us know your preferences regarding our use of photos of you:

Type your full name as a signature.*

Photo of Insurance Card

Max. file size: 2 MB.

If able, please photo and attach image of your insurance card.

Adult Volunteer Medical Form

Emergency Contact Information

Insurance Information

AUTHORIZATIONS

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