top of page

First United Methodist Church

of Fairless Hills

840 Trenton Road - Fairless Hills, Pennsylvania 19030 Phone:  215-946-5800

Fax:  215-946-0664
Reverend Gary Dimovitz


   I                                                                 give my permission for                                            

                                               Parent/legal guardian                                                                                                                                                Name of Youth


   to participate with other members  of the Sr. High Youth Group at

                   Name of the Event                                                     on                                             Date of the Event

     In the un-likey event of an emergency, I give my permission for my child to be treated by an accredited physician in an approved emergency clinic or hospital.  I therefore designate the adult chaperones for the group with authority to act on my behalf and order appropriate treatment. 

     I further release from any liability The Sr. High Youth Group and its officers and leadership in the event of any accident en-route, during, and returning from this event.


                      Signature of Parent / Legal Guardian                                                                        Date

                            Emergency Phone Number                                                                              Allergies



         Participation in church events implies permission to use your likeness in publicity.

bottom of page