Pine Mountain FUMC Youth

206 McDougald Ave N.

Pine Mountain, GA 31822

706-663-2538

Website: fumcpinemountain.org

Email: office@fumcpinemountain.org

PARENTAL PERMISSION AND

MEDICAL AUTHORIZATION FORM

Activity Release

I give permission for my child (named above) to attend the events, field trips, and service projects associated with the Youth Group of Pine Mountain FUMC. I further give permission for my child to be transported to and from events by hired and volunteer drivers authorize by the Pine Mountain United Methodist Church.

I further give permission for my child to participate in all activities sponsored by the Youth Group of Pine Mountain FUMC except.

Medical/Custody Release

I hereby authorize the Youth Group leaders, volunteers, Pine Mountain FUMC, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision,, and upon the advice of or to be rendered by, a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child.

I further authorize the Youth Group leaders of Pine Mountain FUMC to receive physical custody of my child upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to said adult.

EMERGENCY CONTACT INFORMATION