Towson

  United Methodist Church

    501 Hampton Lane

    (Beltway Exit 27B & Dulaney Valley Road)                                  email: towsonumc@towsonumc.org

    Towson, Maryland 21286             410-823-6511                         Elevator is available to access all 3 floors!

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APPENDIX I

POLICY OF THE TOWSON UNITED METHODIST CHURCH FOR THE PREVENTION OF ABUSE OF CHILDREN AND YOUTH

EVENT PARTICIPATION AGREEMENT

Your child will be attending the following event sponsored by The Towson United Methodist Church (“TUMC”):

__________________________________________________________________________________________

Event Information

By signing below, you are agreeing that in case of an emergency, TUMC has your permission for your child to receive medical treatment.

Is your child covered by personal/family medical insurance?     ☐ Yes     ☐ No

[IF YES, PLEASE PROVIDE A COPY OF YOUR INSURANCE CARD]

_________________________________________________________________________________________

Name of insurance carrier                                             Number of policy

Is your child taking medication?     ☐ Yes     ☐ No

If yes, please specify:________________________________________________________________________

_________________________________________________________________________________________

Is your child allergic to anything?     ☐ Yes     ☐ No

If yes, please specify:________________________________________________________________________

_________________________________________________________________________________________

In case of a medical emergency, please contact:

__________________________________________________________________________________________ 

Name                                                                          Phone

By signing below, you are (i) giving permission for your child to attend the above described event, (ii) acknowledging and accepting the risk of property damage, personal injury and any and all other damages of any kind or nature associated with your child’s participation in such event, (iii) accepting personal financial responsibility for any such damage or injury and (iv) agreeing to hold TUMC, its affiliates and its representatives harmless from any and all claims, demands, costs, expenses, liabilities, judgments, sums of money, actions, and causes of action of whatever kind and nature associated with your child’s participation in such event, including, without limitation, those predicated upon negligence.

_________________________________________________________________________________________ 

Parent/Guardian Signature                                            Date