2021/22 HCY Med Form

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 Main Address

Student's Grade:

Student's Email:

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.

Yes No

Parent's Names:

Main Parent Email:

This address will receive a confirmation email

Please list 2 phone numbers of parent/gaurdians of this student:

Parent/Guardian::

Phone

Parent/Guardian::

Phone

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.)

Yes No

Is there any other information you feel the leaders should know in advance about your student?

Hope Cov Media Permission

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.

I accept I do not accept

Last thing! From September 2021 to September of 2022, my child has permission to attend all church sponsored Hope Cov 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 vise 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 accept. I do not accept.

HCY staff will work to…

....pray for your student, your family, and parents.

... commit to investing in your student through discipleship programming, small groups, and HCY adults leaders investing in their lives.

... value and care for each student that comes to HCY.

...provide an atmosphere that allows students to develop personal and lasting relationships with Jesus, other students, and with HCY leaders.

...maintain open communication with students and parents regarding expectation, changes that come up and logistics around programming, retreats, and youth ministry events.

Any questions, comments, or concerns for HCY staff?

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2021/22 HCY Med Form

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