Mission Trip Registration

2021 High School Mission Trip to Virginia Beach

We are going to Virginia Beach this Summer for our High School Mission Trip! Join Roswell Student Ministries for mission projects, worship, and serving with the people of Virginia Beach.
6/19/2021 - 6/25/2021

Additional Information

*Date of Birth: Month/Day/Year- Ex. 04/12/2003
Guest of:
Home Church:
*Adult T-shirt size:
*Please list 3 students you would like to be in a group with:
List any allergies, including FOOD allergies or special needs for child
Do you wear Contact Lenses?:
Are there any activities in which your child may not participate? Please specify.
Operation or Serious Injuries (describe & give dates):
Are Immunizations up to date?:
Date of Last Tetanus Shot:
Recent Illness or Exposure to Contagious Disease?:
List any Medication or Drugs taken regularly (present or recently):
Physician Name::
Physician Address::
Physician Phone #::
Name of Insurance Company::
Name of Insured::
Insurance Group #::
Subscriber ID/Policy#::
Pre-Authorization Phone #::
Insurance Company Street Address::
*Parent(s) Names:
*Parent(s) cell phone number:
*Parent(s) email address:
*Emergency Contact Name:
*Emergency Contact Number- Ex. (999) 999-9999


The medical information listed below is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.

Emergency Authorization – I hereby give permission to the medical personnel selected by Roswell United Methodist Church’s staff or church leaders to order X-rays, routine tests and treatment for my child that he or she may deem necessary. In the event of an emergency and I cannot be reached, I hereby give permission to the physician or other health care professional selected by the RUMC staff or church leaders to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery for my child as named in this document. I further authorize the release of the listed medical information to appropriate medical personnel and/or the health coverage insurance company. I will pay for any medical expenses so incurred. I will notify the church if I feel there are any health considerations that would prevent my child’s participation in any activity. I also give my permission for RUMC staff or church leaders to restrict my child from participation in any activity, which they have any questions about for health or other reasons.

EVENT PARTICIPATION - As the parent (or legal guardian), I the undersigned, certify that my child, named below, has my express permission to participate in all activities, of any nature, sponsored by Roswell United Methodist Church. 

EVENT EXCLUSION - As the parent (or legal guardian), I the undersigned, certify that my child, named below, SHOULD NOT participate in the activities sponsored by Roswell United Methodist Church. If any, please list activity for exclusion below.  

PHOTO RELEASE - I grant permission to Roswell United Methodist Church (RUMC) to take and use photographs of my child for use in church-related publications such as brochures and newsletters, and to use the photographs on display boards, and to use such photographs in electronic versions of the same publications or on the RUMC web sites or other electronic forms or media, and to offer them for use or distribution in publications outside RUMC, electronic or otherwise, without notifying me.

I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photograph.

I hereby agree to release, defend, and hold harmless Roswell United Methodist Church and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

I have carefully read this release of liability and understand its contents.  Therefore, I fully release Roswell United Methodist Church, its authorized representatives, and staff from all liability of any kind and character upon any claim, demand, or cause of action, which might be asserted, in our behalf against said church, representatives or staff.

I certify that I have read the above releases and by entering my name below, I agree to be legally bound by these releases. I agree that my electronic signature is the legal equivalent of my manual signature as if signed by myself in writing.
*Electronic Signature acknowledging Medical Release
*I give permission for my child to be in photographs for RUMC.
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