HCY Med Form
Please fill out this form and click submit.
If you have multiple students in Hope Cov Youth please fill out a form for each student. Thank you!
Student's Name
Student's Birthday
Student's Address
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Student's Grade:
Student's Email
Optional
Does your student have a cell phone? Can we get their number? WE LOVE TO TEXT OUR STUDENTS ENCOURAGEMENT & EVENT DETAILS.
We give our child our permission to attend Hope Covenant Church’s Youth Ministry events and to be transported in an adult leader’s personal vehicle. If we cannot be reached, we hereby give Hope Covenant, Rachel Lassen, or other adult leader on the Hope sponsored youth event, to consent on our behalf to any such emergency care and treatment being rendered by any duly licensed doctor or dentist. We release from liability and responsibility, Hope Covenant Church and the adult leaders, except in the case of gross negligence.
Please select all that apply.
Yes
No
Parent's Names:
Parents Emails
This address will receive a confirmation email
Please list 2 phone numbers of parent/gaurdians of this student:
Who would be an alternate emergency contact for this student?
Can we have the emergency contact's phone number?
What is your Health Insurance Company and Policy #? (for emergencies)
To best support your student, are there any conditions/allergies/chronic/recurring illness/medical conditions including mental illness (depression, anxiety) that we should be aware of?
In case of emergency, are there current medications your student takes that we should know about?
May we administer over-the-counter-medications? (e.g., aspirin, Tylenol, Advil, antibiotic ointments, etc.)
Please select all that apply.
Yes
No
In other information you feel the leaders should know in advance about your student?
Last thing! From May of 2020 to September of 2021, my child has permission to attend all church sponsored youth activities as listed in calendars and/or on the Hope Covenant emails and website, including but not limited to the following: lock-ins, cook-outs, swimming, games in the park, bonfires, retreats, Bible studies, etc. I acknowledge these rules of conduct expected from each participant and parent: Respect one another, staff, and adult leaders Respect property Participation with the group expected No offensive or immodest clothing No offensive or inappropriate language No lighters permitted No fighting, weapons, fireworks, or explosives No students permitted to drive for events No boys in girls’ sleeping quarters and vis versa Respect and comply with event schedules I and my child acknowledge that misconduct may result in transportation home from an activity at the parent’s expense. A student dismissed for a disciplinary reason will not receive a refund of ANY activity fee. My child and I agree to follow the instruction of the pastor, leader, or volunteer who has been delegated leadership authority. I understand and authorize that my child’s image may be photographed or filmed and used in Hope Covenant Church video presentations, printed publications, Web site, Facebook page, and photo directories
Please select all that apply.
I accept
I do not accept
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