Release of Liability
Bethany UMYF General Release of Liability Form
All students participating in Bethany UMYF off-site activities during the 2006-2007 school year are required to complete
this form. Parents may be asked to sign the back of this form for individual events or to update the data. Separate
permission slips for overnight or special events may also be used.
Name of youth __________________________________________________________________
Address __________________________________________________________________
Home phone number _____________________________
Name of parents or guardian _____________________________
Work phones and cell phones _____________________________
Other emergency numbers _____________________________
Name of pediatrician/doctor _____________________________
Doctor’s phone number _____________________________
Insurance carrier _____________________________
Policy numbers _____________________________
My youth has the following medical conditions or is taking the following medications which program leaders should be
aware of:
_____________________________________________________________________________
I hereby give the adult leaders of Bethany’s youth program the authority to accept medical treatment for my child in the
event that I cannot be reached. I also give my child permission to ride the vehicle of an adult leader in order to
participate in the youth program.
Signature ____________________________________ Date __________________
All students participating in Bethany UMYF off-site activities during the 2006-2007 school year are required to complete
this form. Parents may be asked to sign the back of this form for individual events or to update the data. Separate
permission slips for overnight or special events may also be used.
Name of youth __________________________________________________________________
Address __________________________________________________________________
Home phone number _____________________________
Name of parents or guardian _____________________________
Work phones and cell phones _____________________________
Other emergency numbers _____________________________
Name of pediatrician/doctor _____________________________
Doctor’s phone number _____________________________
Insurance carrier _____________________________
Policy numbers _____________________________
My youth has the following medical conditions or is taking the following medications which program leaders should be
aware of:
_____________________________________________________________________________
I hereby give the adult leaders of Bethany’s youth program the authority to accept medical treatment for my child in the
event that I cannot be reached. I also give my child permission to ride the vehicle of an adult leader in order to
participate in the youth program.
Signature ____________________________________ Date __________________
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