Consent Form

*(denotes required field)

Students Full Name *

Date of Birth *

Gender:

male female

School *

Home Address

Street *

City *

State *

Zip Code *

Home Phone *

Student's Cell Phone *

Student's Email Address

Mom's Name *

Mom's Cell Phone Number *

Mom's Email Address

Dad's Name *

Dad's Cell Phone Number *

Dad's Email Address

Do you attend another church:

yes
no

If yes, what church?

Please Read the Following
I/We give permission for my/our child, named above, to attend and participate in activities/events/sports ministry sponsored by Hope Reformed Church, South Haven.
I/We understand all reasonable safety precautions will be taken at all times by Hope Reformed Church and its agents during events/activities.
I/ We understand and agree that my child's participation in athletic and other activities of the program involves the risk of injury and even death from various causes, including but not limited to accidents, strenuous and prolonged physical activity, dehydration, illness, collision, weather related inuries, playing area and equipment defects, and negligence of coaches and referees. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I assume these risks.
I/We herby release, discharge, hold harmless and indemnify, and covenant not to sue Hope church and directors, officers, elders, deacons, employees, volunteers, insureers, agents and representatives, and all other persons associated with SMACK and SnL.
I/We give permission for my/our child to ride in any vehicle driven by an adult leader, in whose care he/she has been entrusted, including permission to drive my/our child to and from youth activities.
I/We authorize the adult volunteers/leaders from Hope Reformed Church to consent to any X-ray, anesthetic, medical, surgical, or dental diagnoses and/or treatment, and hospital care to be given to my/our child on the advice of a physician or dentist or a licensed hospital in the event of an emergency. I also agree to be responsible for all costs and expenses in connection with medical, dental or optical services.
I/We consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of my/our child/ren to be used by Hope Reformed Church sees fit for brochures, video presentation, on the website of Hope Reformed Church and/or any other media venues.
I/We give Hope Reformed Church permission to follow all escape/safety procedures listed in its Safety Policy in the event of a Nuclear emergency.
I/We acknowledge that if my/our child/ren has to return home early for discipline violations, it will be at my/our expense.
I/We agree that my child is healthy and able to participate in SMACK and SnL activities and sports ministries and also agree that should my child become unable to play/attend these activities due to sickness or other health issues it is my responsibility that they do not attend or participate.
Writing your name below indicates that all information provided in this form is true and accurate and that I fully agree to all statements made on the form, including but not limited to the Authorization and release of liability, medical conditions, and consent to medical treatments.
Electronic Signature: By putting your name below it is considered an electronic signature.

Parent/Guardian Electronic Signature (please enter your full name) *

Emergency Contact (If Parents cannot be located) - First Option

Full Name *

Phone Number *

Emergency Contact (If Parents cannot be located) - Second Option

Full Name *

Phone Number *

Please list any allergies, medications needed, physical concerns, or other information that may be helpful.

Insurance Company Name *

Insurance Policy Number *

Please have your child read the following and sign at the bottom to indicate he/she will abide by all guidelines and traditions!
Guidelines of Expected Behavior of Each Student:
1. No alcohol or drugs are permitted at any activity/event.
2. No smoking is permitted at any activity/event.
3. Reporting to and checking in with leaders is mandatory.
4. Abiding by the rules and guidelines of all adult leaders.
5. Meeting at designated place by leaders on time or ahead of scheduled time for activity/event.
6. You must stay with the group at all times. No leaving! No exceptions!
7. If you are aware of someone NOT following guidelines, you must report it to a leader.
SMACK and SnL Small Group Traditions
1. Respect others when they are talking
2. Whatever is said in small groups stays in small groups
3. Have FUN, participate in EVERYTHING!
4. No name dropping (no need to use names of people when telling a story).
5. Keep hands feet and other objects to yourself.

By filling in your name below, you agree to the Guidelines of Expected Behavior as outlined above.

Student's Electronic Signature (please enter your full name) *

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