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Mendham Hills Community Church Student Release Form

September 2024 - August 2025 


PLEASE READ ALL INFORMATION & INITIAL EACH SECTION - YOUR SIGNATURE IS REQUIRED AT THE BOTTOM.

LIABILITY RELEASE AND CONSENT TO TRAVEL

I, being an adult (of 18 years or older) or the parent/legal guardian of named minor, do hereby release Mendham Hills Community Church, its agents, assigns, employees, and volunteer assistants from any liability whatsoever arising out of injury, sickness, damage, or death, which may be sustained by myself or the above minor during any activity, trip, function, or the like-sponsored by or participated in by Mendham Hills Community church from September 2024 through August 2025.

I also give my permission for the above named minor to attend and be transported to any activity, trip, function or the like sponsored by Mendham Hills Community Church from September 2024 through August 2025 by a director or properly appointed adult sponsor of the student ministry of Mendham Hills Community Church.


MEDICAL RELEASE

I, being an adult (of 18 years or older) or the parent/legal guardian of named minor, do hereby give my consent for the youth pastor or properly appointed adult sponsor of the student ministry of Mendham Hills Community church to secure the administration of medical treatment or medication for the above named individual and do further agree to the performance of such treatment, anesthetic, and/or operations, as in the opinion of the attending physician is deemed necessary for myself or the above named minor while at any activity, trip, function, or the like sponsored by Mendham Hills Community Church from September 2024 through August 2025.

I have informed Mendham Hills Community Church of all prescribed or over-the-counter medications that I or my minor are currently taking, all restrictions on medical treatment to be provided, of all allergies to medications and of special medical requirements by listing them on the reverse side of this form.



DISCIPLINARY AGREEMENT

 I, being an adult (of 18 years or older) or the parent/legal guardian of named minor, understand while I or the above named minor participates in any activity, trip, function or the like either sponsored by or participated in by Mendham Hills Community Church from September 2024 through August 2025, I or the above named minor, is responsible to abide by the rules set forth by the sponsored organization, its leaders and/or all supervisory personnel.

Any infraction of rules and/or conduct by the above named person(s), deemed to be serious by any director or properly appointed adult sponsor of the youth ministries of Mendham Hills Community Church, can result in corrective action, up to and including dismissal from the event. In the event that I or the above named minor is dismissed from the program, I or the minor’s legal guardian agree to assume the entire cost of returning home, to forfeit any monies paid for the cost of the trip/event, and to assume responsibility for any monies owed for the cost of the trip/event. I or the above named minor fully understand and agree that there will be no refund of the cost of returning home.


IMPORTANT PARENT INFO

Timely drop off and pick up on Sunday nights and for events is very important for the safety and security of your students, and the respect of our volunteers’ time. Early drop off is not permitted, and prompt pickup is required.

For the safety and security of your students, parents and other adults (with the exception of MHCC staff and official youth leaders) are not permitted to be in the MHCC buildings during youth group. You are welcome, however, to come in at drop off to help your child get acclimated or when you pick them up at the end of the evening/event.

Students may not leave early without parental permission communicated by the parent directly to youth ministry staff or volunteers. Please be specific regarding the time of pickup or departure.


THERE IS ZERO TOLERANCE FOR THE FOLLOWING AT AN MHCC STUDENTS ACTIVITY OR EVENT

Tobacco, alcohol, drug use/possession

Showing up under the influence of alcohol or drugs

Sexual activity

Weapons

Bullying and/or intimidation


 CONFIDENTIALITY & REPORTING

In order to promote trust and open dialogue with your student, most things he/she discusses with the youth pastor and youth leaders are kept confidential. If your student is struggling, has a diagnosis, or is in treatment, you are encouraged to talk to the youth pastor about it. Knowledge increases understanding and understanding informs appropriate responses. That said, there are three situations that are NOT kept confidential:

A student threatens to harm or does harm another person or people. Parent(s) will be contacted. If the threat is egregious, the police will be called immediately.

A student threatens to harm himself/herself or is currently harming himself/herself. Parent(s) will be contacted immediately.

A student says that someone is abusing them. In the state of New Jersey, MHCC staff and volunteers are mandated by law to report. There is no room for personal interpretation, and we have no choice, no matter how long we have known the people involved or whether or not they are part of MHCC; Child Protective Services must be called.

Please sign below to acknowledge that you have read and understand the above information. If you have questions, please feel free to contact the youth pastor.


I agree to all of the above statements and all information provided on the reverse of this form is complete, accurate and true to the best of my knowledge.

November 14, 2024


Please select MINOR for your student
AdultMinor
Continue
First Student's Name

First Name*

Last Name*

Phone*
First Student's Date of Birth*
First Student's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Medications

Are there any medication allergies? *

Are there any medications or treatments that should not be given to the student because of adverse or dangerous reactions? (Please list reaction) *

Medications taken regularly by the student (List all over the counter and Rx): *
Medical History

Any other allergies in addition to medications listed above? *

Are there any medical conditions or physical limitations or disabilities that the student may have that would limit his/her ability to participate in any activity? *

Anything else we should be aware of? *
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*

Phone*
Parent or Guardian's Date of Birth*
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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