Parental Medical Authority for All Youth Trips

First United Methodist Church Tupelo, MS

412 W. Main St.
Tupelo, MS 38804
(662) 690-8100
In case of emergency, I authorize the church leaders to take _____________________________
to a nearby medical facility, and also give my permission for medical attention to be administered by the
medical service provider, (By church leader I mean the FUMC Tupelo Senior Minister, Fred Britton,
the Student Minister, Jay Becker and/or any pertinent FUMC Tupelo adult).
I am listing pertinent medical history and information, and I will notify the church office in writing of any
changes in this information.
My medical insurance policy number is _________________________________________ with
(Company) _____________________________________ and may be used to cover the needs of my
child.
My employment: _________________________________________ Office:(662)___________________
My relationship to youth ___________________________________ Home(662)____________________
Full name of youth _______________________________________Birthday_______________________
Social Security Number of youth ______________________________
Emergency Contacts: (Give name, full address, phone numbers and relationship to youth)
_____________________________________________________________________________________
_____________________________________________________________________________________
Current Medication:
_____________________________________________________________________
Allergies:
_____________________________________________________________________________
Medicine to which youth is allergic:
________________________________________________________
Regular Physician: ___________________________________Phone: (662)________________________
Trip #1________________________ ___________ Trip #4_________________________ _________
Signature
Date
Signature
Date
Trip #2________________________ ___________ Trip #5___________________________________
Signature
Date
Signature
Date
Trip #3________________________ ___________ Trip #6_______________________________
Signature
Date
Signature
Date
PLEASE INCLUDE A COPY OR PICTURE OF FRONT & BACK OF INSURANCE CARD
*** This permission slip is valid from Jan. 1, 2016 through Jan. 1, 2017 ***