Emergency Contact Information
Medical Statement of Consent
I understand that in the event of a medical emergency every effort will be made to contact the parent or guardian listed above. However, in the event that the above named parent or guardian cannot be reached, I hereby authorize the church minister(s), staff members, or adult volunteer(s) present on such a trip, activity or event to select such physicians, nurses, medical authorities, and/or hospitals to administer proper treatment for my child and/or to order and administer to him/her such injection, medication, anesthesia, surgery, hospitalization or such other medical practices as they deem necessary.
I am aware that my student will be given the choice to participate in activities that may be physically and emotionally demanding and where certain inherent risks and dangers may exist. I recognize that there is an element of risk in any adventure, sport, or activity. My student may be exposed to extraordinary physical hazards, weather conditions, or other unknown elements. I have noted any and all conditions which may affect my student’s participation on this Medical Release Form*. I do hereby assume all risks and I agree to release and hold harmless First United Methodist Church of New Philadelphia, its representatives assistants, employees, and all related entities from any all liability, lost or damage actions, claims and demands, which my student now has or which may arise from their participation in these activities. This shall serve as a release and assumption of risk for their heirs, executors, and all personal representatives.
I further state that I have listed above all known allergies and health problems for my child and any other information pertinent to his/her health, including medication he/she takes. I agree to revise the information as it may change so that the above reflects the current health status of my child at any given time.
I hereby grant permission for you to photograph, videotape, and/or to record my voice and sounds and to use any or all such photographs, recordings, and reproductions thereof in and/or as a part of any motion picture, video production, broadcast, published products, related advertising (including internet/websites), displays, or in exhibition uses. I further grant the use of my name in connection with my comments and opinions.
I hereby grant and assign to First United Methodist all non-exclusive rights of every type and nature and the unlimited distribution and other utilization of the pictures, images, tapes or products by any method or in any manner and in any and all media, including theatrical, non-theatrical, radio, videocassette, television, electronic usage, and printed products, and to advertise and publicize said products, in perpetuity, throughout the world.
I hereby waive any right that I may have to inspect or approve the finished product and the advertising or other copy that may be used in connection herein. The parties to this contract expressly agree that the laws of Ohio shall govern the validity, construction, interpretation, and effect of this contract.
If I no longer desire to abide by this agreement, I will contact First United Methodist to remove myself from this photo release.