Winter Retreat
February 7th - 9th, 2025

Student Participation Authorization and Consent to Emergency Medical Treatment

Student Information

Student First Name

Student Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Birthdate

Student Age

Grade

Phone Number

Gender

Allergies

Medications

Parent Information

Parent FIrst Name

Parent Last Name

Parent Cell Number

Additional Parent Phone

Medical Insurance Co.

Policy Number/ID

Group Number

Authorization, Release of Liability, and Consent for Medical Treatment:

I, the undersigned parent/guardian, authorize permission for the above student to attend this trip sponsored by Hope Community.

Agree

Disagree

I give my permission for my child to be photographed. I understand these photographs will be used at the church's discretion.

Agree

Disagree

I authorize any adult leader to consent to obtain such emergency medical care or treatment as may be necessary should any injury, harm or accident occur to the above student while participating in the trip. I understand and acknowledge that Hope Community does not provide health or medical insurance in connection with this trip and I agree that I will be financially responsible for any bills incurred as a result of medical treatment, including emergency medical treatment and/or transportation to a medical facility, in connection with the above student's participation on this trip. Should it be necessary for my child to return home due to medical reasons, disciplinary action or otherwise, I hereby assume all costs involved.

Agree

Disagree

As parent/guardian, I do hereby release, forever discharge and agree to hold harmless Hope Community, its board, employees, agents, or representatives from any and all accidental and unintended liability, personal injury, sickness or death which may occur while participating in the trip. I assume all responsibility as a result of the above student’s participation in this church-sponsored activity. This is a binding covenant and agreement.

Agree

Disagree

Signature

Date Input

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Winter RetreatFebruary 7th - 9th, 2025

Student Information

Parent Information

Authorization, Release of Liability, and Consent for Medical Treatment:

Winter Retreat
February 7th - 9th, 2025