Heights of Hope Youth Permission Form 2023-2024

Please fill out this form and click submit.
NO STUDENT WILL BE ALLOWED TO TAKE PART IN HEIGHTS OF HOPE PROGRAMS WITHOUT A COMPLETED FORM ON FILE.
Parent/Guardian Information

 
 
 
 
 
 
 
Please select all that apply.
Child 1 Information

 
 
 
 
 
Please select all that apply.
Please select one option.
Child 2 Information

 
 
 
 
 
Please select all that apply.
Please select one option.
Child 3 Information

 
 
 
 
 
Please select all that apply.
Please select one option.
Emergency Contact Information

 
 
 
Media Release

Please select all that apply.
Special Needs

 
 
 
 
 
 
 
 
Digital Signature

The information on this form is correct so far as I now, and the person(s) herein described has permission to engage in any Heights of Hope youth programs, except as noted by me.

I give permission for my child to be transported by Heights of Hope staff and leaders for programs and events. I also release the program leaders from all liability for accidents incurred on trips or at programs as long as the program leaders are not grossly negligent.

In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the program leaders to hospitalize, secure propert teatment for, and to order injections, anesthesia, or surgery for my child as named above. In case of emergency, I understand that every effort will be made to contact me. If I cannot be reached, I hereby give the program leaders permission to act on my behalf in seeing emergency treatment for my child in the event that the program leaders deem such treatment necessary. The parent or guardian understands that this authorization is given also to authorize any hospital, which has provided treatment to the child to return physical custody of the child to the adult staff members when treatment is completed.

This form is valid for the duration of the school year and summer unless revoked in writing and delivered ot the Heights of Hope office at Calvary Reformed Church.

By submitting this form I acknowledge that it serves as my electronic signature giving permission for the above described activities.

 
 

Description

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