I hereby give my child permission to participate in the Wesley Chapel High School Mission Trip June 29-July 6. I release Wesley Chapel UMC, its staff, leaders, and sponsors from responsibility and liability for any injury or illness that my child may sustain during this activity. In the event of an emergency, I hereby authorize an adult leader of this activity, as agent for me, to consent to an x-ray examination; medical, dental, or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either in a doctor's office or in a hospital. I expect to be contacted as soon as possible.

Early Return Home Policy: Should it be necessary for our/my child to return home due to medical reasons, disciplinary action, or otherwise, the undersigned parent/guardian shall assume all transportation costs and responsibilities.

By signing this form, I also give permission for my child to be photographed or videotaped at this event. Pictures/Videos will only be used for promotional or educational purposes and only by Wesley Chapel UMC.

Child's Full Name (required)

Date of Birth (required)

Complete Address (required)

Phone Number

Cell Number (required)

Emergency Contact Name and Phone # (required)

Your Email (required)

Medical Information
Existing Condition/Physical Limitations

Medications being taken (if any)

Will your Youth need to take any medication while away? (required)

If yes, please list medication and instructions

Family Physician and Address and Phone # (required)

Insurance company, Name of insured, and Policy #(required)

My electronic signature below is my authorization and release to Wesley Chapel UMC and gives my child permission to participate with Wesley Chapel UMC Youth and I acknowledge that I have read this form and understand.(Please type your name and date in the space provided)