Medical Form

Medical Liability Release Form
Check all of the following in which you/the participant will be involved:*


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Please note that this medical form will not be valid until we have a copy of the front AND back of the responsible party's insurance card. This can be attached at the bottom of this form.

Or, if submitting via email or hard copy, must be submitted within 3 days of submitting this medical form to Karen Payne in the Youth Ministries office (, 704-892-8277).


We realize that information contained in this form is sensitive and personal. Only paid adult staff and adult volunteers working directly with the participant named on this form will have access to this information. The more fully the form is completed, the better we will be able to meet individual needs.



Participant carries an EpiPen.


Participant has the following dietary restrictions:

Chronic Concerns

Participant has the following chronic health concerns (check all that apply):


My child/youth is NOT allowed to take the following over-the-counter (OTC) medications:

If administered an OTC medication, my child/youth should receive:

Youth in Grades 9 - 12

NOTE: For ages newborn to Grade 8, ALL medications (prescription and OTC) MUST be administered by adult leadership.


Special Needs/Disability Awareness

Participant has the following diagnosed special needs (check all that apply):

Davidson United Methodist Church (DUMC), its representatives, and employees may take photographs during DUMC-related activities. DUMC reserves the right to use those images, without compensation, in print and/or electronic communications for any lawful purpose, including publicity, illustration, advertising, and Web content (DUMC website, Facebook, Twitter, or Instagram).


My child/youth has permission to receive routine first aid care and the prescription and/or OTC medication(s) indicated on this form during their participation in DUMC activities. I understand that in the event medical intervention is needed, every attempt will be made to immediately contact the persons listed on this form. In the event the emergency contacts cannot be reached, I hereby give permission to the physician/dentist selected by the activity leaders to hospitalize, secure medical treatment, an injection, anesthesia, or surgery as deemed necessary. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Davidson United Methodist Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the participant.

This can be attached at the prompt below. Or, if submitting an email or hard copy to Karen Payne (, please do so within 3 days of submitting this medical form.