UTX Permission Form

2016-2017 UTX(under the cross) After School Program Permission Form


UTX will be meeting most Wednesday’s during the academic year at Eureka United Methodist Church (EUMC).  We will offer transportation from the middle school to the church. Afternoon activities will include snacks, praise/worship/devotional time, small group discussion, and structured large group activities.  UTX ends at 4:45pm.

Please fill out this form and e-mail it back to tim.schulte@eurekaumc.org or send it with your student to the first UTX they attend. Please notify EUMC via this e-mail address or by sending a text to 314-220-4324 no later than 10pm on the evening prior to each UTX.  A text or e-mail must be sent each week for each student(s) and their friend(s) so that we can plan adequate transportation to/from the various middle schools each week. Our drivers will only allow students with a permission form on file and those who have indicated that they will attend that week (via text or e-mail) to board the vehicle(s). This form just needs to be submitted once during the academic school year.


Name of Participant ___________________________________

Address ________________________________________________________________

City ____________________________ State ____________ Zip Code ______________

Home Phone ____________________Cell Phone________________

Grade ______________ School Name______________________________________

Date of Birth ________________Male________ Female_________


Parent or Guardian ________________________________________________________

Address ________________________________________________________________

Home phone___________________work  phone__________________________

Cell phone___________________________

e-mail ______________________________



We will be serving snacks at UTX. Does your child have any food allergies or medical



UTX participants will be picked up at LaSalle Springs, Rockwood Valley, Wildwood, and/or Meramec Valley by our bus, van, and/or private vehicle(s).

I give permission for my child to ride to EUMC with an adult UTX leader(s) by bus, van, and/or private vehicle __________

My child already has transportation to EUMC _____________

Who is allowed to pick up your child from EUMC?______________________________

Photograph Release

I give UTX/EUMC permission to photograph my child for use in the EUMC newsletter, church website, UTX facebook page, etc.

Parent/Guardian Signature _____________________________ Date ________________

Eureka United Methodist Church, 215 N. Central, Eureka, MO 63025    636.938.6377

EUMC and UTX student ministries adhere to the safe sanctuaries policy set by our local church leadership and/or our church conference.  This includes tri-annual training, certification, and background checks at the state level for each adult leader. More information about this policy is available upon request.