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We require a Hope Students Medical Release form to be on file for all students who participate in activities and events at Hope Church. We ask that you fill two of these forms out each year- one for activities during the school year (September 1 - April 30) and one for activities in the summer (May 1 - August 31). 


Student Consent:
For your information, we expect each student to conform to these rules of conduct: 
            No possession or use of alcohol, drugs, or tobacco
            No students can drive
            No fighting, weapons, fireworks, lighters, or explosives
            No offensive or immodest clothing
            No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters
            Participation with the group is expected
            Respect property
            Respect one another, staff, and adult leaders
            Respect and comply with event schedules

Students who fail to comply with these expectations may be sent home at their parents’ expense.

I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth group activities. I agree to abide by the stated personal limitations and code of conduct. 

Please have your student initial in the box below: 



 

Photography Disclosure: 

I understand that there will be photographs taken of my child during ministry trips and activities with Hope Church and that these photographs may be used without my consent for social media and/or advertising and publicity purposes. 

Liability Release & Medical Consent: 
The consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. 

In the event that the student is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our expense should they become ill or if deemed necessary by the student ministries staff member. 



 

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Medical History: If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken. All this information will be kept in the strictest of confidence and safeguarded by the activity/event leader.
For your child's safety and our knowledge, is your student a-*
Does your child have allergies to-
Pollens
Medications
Food
Insect bites
Does your student wear contacts/glasses?*
Yes
No

If so, please list all allergies and medications:
Does your child suffer from, has ever experienced, or is currently being treated for any of the following:
Asthma
Epilepsy/Seizures
Heart trouble
Diabetes
Frequent upset stomach
Physical handicap

Please list and explain any major illnesses your child experienced during the last year:

Additional Comments:

Should the child's activities be limited for any reason? Please explain:
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Medical History: If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken. All this information will be kept in the strictest of confidence and safeguarded by the activity/event leader.
For your child's safety and our knowledge, is your student a-*
Does your child have allergies to-
Pollens
Medications
Food
Insect bites
Does your student wear contacts/glasses?*
Yes
No

If so, please list all allergies and medications:
Does your child suffer from, has ever experienced, or is currently being treated for any of the following:
Asthma
Epilepsy/Seizures
Heart trouble
Diabetes
Frequent upset stomach
Physical handicap

Please list and explain any major illnesses your child experienced during the last year:

Additional Comments:

Should the child's activities be limited for any reason? Please explain:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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