Please check the trips listed below that apply to your students. Only one set of PRUMC forms will
need to be filled out per year. There may be other required forms depending upon each trip. An up
to date insurance card is required as well.
Student Name:__________________________________
Parent Signature:________________________________ Date:___________________
_____________ Ski Trip – Snowshoe WV
_____________ Boys Retreat – Burge Plantation
______________ Girls Retreat – Camp Skyline
______________ High School Mission Trip – Leon, Nicaragua
______________ Middle School Mission Trip – Asheville, NC
_______________ Various trips throughout the year that may include Six Flags, Whitewater, etc.
and service projects.
Peachtree Road United Methodist Church
Parental Release & Medical Form for 2016
On any trip in which ____________________________, my child (or ward), participates or in connection
with any other activities or events in which my child (or ward) may participate that are held, supervised,
conducted or sponsored by Peachtree Road United Methodist Church (PRUMC). I hereby waive, satisfy and
relinquish all claims which may arise, and do hereby, for myself and my child (or ward) waive, satisfy,
release and forever discharge PRUMC and its affiliates, its officers, directors, trustees, employees,
volunteers, servants, agents, successors and assign from and against any and all claims, demands, costs,
expenses, liabilities, judgments, sums of monies, actions and causes of action of whatever kind and nature
including, without limitation, those predicated upon negligence. This is intended to be a general release and
waiver including, but not limited to all claims for property damage, contract damage, personal injury, special,
general, direct and consequential damages, loss of profits, loss of consortium and any and all other damages
of any kind or nature.
I further authorize any adult chaperon or volunteer of PRUMC to approve any medical treatment which
might be required during any such trip or activity.
_______________________________________________
Signature of Parent or Guardian
___________________
Date
Please list any known allergies and/or preexisting medical conditions:
_______________________________________________________________________________________
_______________________________________________________________________________________
Gender_____ T-Shirt Size _______________ E-mail Address____________________________________
Medical Insurance Information: if your information changes, it is your responsibility to update it with us!
Company________________________________
Policy # __________________________
Emergency Phone Numbers
Parent/Guardian’s Name ____________________
Home # ____________________
Cell # __________________________
Work # __________________________
Other Emergency Contacts
Name ___________________________________
Phone #__________________________
Name ___________________________________
Phone #__________________________
*I give my permission for photographs / videos of my child to be taken and used in
future promotional materials on the church website or in hard copy form.
___Yes ___No
Signature:_________________________________
***Please attach a front/back copy of the student’s insurance card.***
Jon Jones, Director of Student Ministries
3180 Peachtree Road NW, Atlanta GA 30305
Phone: 404.240.8238 Fax: 404.266.0734 Email: [email protected]
Peachtree Road United Methodist Church
Youth Covenant
YOU SHOW THAT YOU ARE A LETTER FROM CHRIST, WRITTEN NOT WITH INK BUT WITH
THE SPIRIT OF THE LIVING GOD.
2 CORNITHIANS 3:3
What an awesome thing to be – a letter from Christ to others! It’s also an awesome challenge and
responsibility. If we are letters from Christ, then what we say, what we do and what we choose should
reflect our love and devotion to Christ. This makes the saying “What would Jesus do?” even more real. As
we travel together, let’s keep a covenant between each member of our group and God to be letters from
Christ in all that we do. Let’s keep in mind what Jesus would do in every situation.
Jesus commanded us to love our neighbors as ourselves. We do this by showing kindness and respect.
Therefore…
We will love and respect our peers, our adult leaders and the retreat facilities by:
• Following through with our jobs and responsibilities
• Using kind words and no put-downs
• Using appropriate language
• Following guidelines set up by the adult leaders and the retreat center
• Asking to borrow and returning other people’s property in good condition
• Refraining from writing, drawing or carving on the walls of cabins and lodges
We will love and respect ourselves by:
• Following through with our jobs and responsibilities
• Refraining from using tobacco products, drugs, alcohol or fireworks
• Refraining from any sexually inappropriate actions
As a group we want to show our love for each other and for Christ. We want others to see God in us. We
want to do what Jesus would do.
*By signing this covenant, I understand and agree to abide by the above expectations and I give
consent to PRUMC staff to search my bags for inappropriate items when necessary.
_____________________________
Youth Signature
________
Date
_____________________________
Parent Signature
________
Date
***VIOLATIONS OF THESE RULES COULD RESULT IN PARTICIPANT BEING SENT HOME
AT PARENTS’ EXPENSE***