Adult Medical Release Form

Adult Volunteer Medical Form

  • MM slash DD slash YYYY
  • Emergency Contact Information

  • Insurance Information

  • If none, please note N/A.

    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:
  • Max. file size: 2 MB.
    If able, please photo and attach image of your insurance card.