theCENTRE Permission Slip

Permission to travel & participate / Liability release:

I/We, the parent(s)/ guardian(s) of the above-named minor, do hereby give him/her permission to travel with the youth group of Hope Community Church and to participate in all youth activities and functions during the time period of January, 1 2020 through January, 1 2022. I/We understand that the above-named minor may be traveling via public or private transportation (for example: car, bus, boat, van, plane etc…). I/We hereby recognize the inherent risks associated with the various youth activities and forms of travel, and agree to save and hold harmless Hope Community Church and their employees, volunteers, and agents from any liability or expense that may arise from the above-named minor participating in the youth events and any travel related incidents going to and from such events.

Authorization of consent to treat minor:

I/We, the parent(s)/guardian(s) of the above-named minor, do hereby authorize Hope Community Church, employees, youth group leaders, servants, officers, and adult volunteers as agents for the undersigned to consent any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and or to be rendered under the general or specific supervision of any physician or surgeon licensed under the provision of the Public Health Code, whether such diagnosis or treatment is rendered at the office of said physician authority and power is understood that this authorization is given in advance of any specific treatment or diagnosis, but is given to provide authority and power of treatment, or hospital care which the aforementioned physician in the exercise of best judgement may deem advisable. This authorization shall remain effective for the time period stated above, unless sooner revoked in writing delivered to said agent(s).

Release of liability:

I/We the parent(s)/guardian(s) of the above-named minor, shall indemnify, hold free and harmless, assume liability for, and defend Hope Community Church, its agents, servants, employees, volunteers, officers and directors from any and all costs and expenses including but not limited to, medical fees, attorney's fees, discovery costs, court cost, and all other sums associated with any claim or action founded thereon, including those arising or alleged to have arisen out of treatment of the above-named minor. I/We also release Hope Community Church and any agents of the church of any liability incurred due to the above-named minor's use of real or personal property belonging to Hope Community Church, its agents, employees, and volunteers.

HopeCC Permission Slip/Emergency Release

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Parent/Student Info


Virtual Signature

By consenting and submitting your name below, you, as the parent/guardian, acknowledge that you have read, understood, and agree to the information presented and affirm that the information you have provided is correct and complete.