Fusion Emergency Waiver/Parent Release Form 2026

An adult must fill out this form for their child. When it says "your name" please type the child's name. Add their e-mail address if they have one, if not, type in yours.

Your name *

Last name

Email address *

Birthdate

Father's Emergency Contact Information

Name

Phone number

Phone type

Mother's Emergency Contact Information

Name

Phone number

Phone type

Emergency Contact - other than father and mother

Name *

Phone Number *

Medical Information

Medical Insurance Company *

Policy Number *

Physician's Name *

Physician's Phone Number *

Dentist's Name *

Dentist's Phone Number *

Medical information we need to be aware of:

If necessary, describe in detail any: physical and/or psychological ailment, illness, weakness, handicap, disability, or condition to which your child is subject and of which staff should be aware, and what, if any action of protection is required on account thereof. Include names of medications and dosages that must be taken.

Allergies: *

Please check all that apply:

pollens

medications

food

insect bites

none

Other

Does this person suffer from, or have ever experienced any of the following? *

asthma

epilepsy/seizure disorder

heart trouble

diabetes

frequently upset stomach

physical handicap

none

Other

Please list/explain any major illnesses this person experienced during the past year.

Should this person's activity be limited for any reason? Please explain.

Does this person wear contacts/glasses? *

Yes

Consent Form

This consent form gives permission to seek whatever medical attention is deemed necessary and releases the Hopewell Church and its staff of any liability against personal losses of the named person. I the undersigned have legal custody of the named person, a minor, and have given consent for him/her to participate in events with Hopewell Christian Fellowship and Fusion Youth Ministry. I understand that there are inherent risks involved in any ministry or athletic event, and I release the church, its pastors, employees, agents, and volunteer workers from any and all liability for injury, loss, or damage to person or property that may occur during the course of my child's involvement. In the event that I/he/she is injured I consent to reasonable medical treatment as deemed necessary by a licensed physician.

In the event treatment is required from a physician and/or hospital personnel designated by the church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further I affirm that the health insurance information previously provided and on file is accurate at this date and will, to the best of my knowledge, still be the force for myself/student named. I also agree to travel to bring my child home at my own expense should I/they become ill, or if deemed necessary by the church's staff.

I also acknowledge that photographs and videos may be taken of my student at events and may be used for promotional purposes including, but not limited to, fliers, banners, and the church/youth ministry website. This also includes Live Streams included on but not limited to the Hopewell app, Youtube, Facebook, Instagram, etc. for services such as but not limited to Wednesday night Youth Group/Fusion Sunday/off site events, etc.

Check that you have read and accept the preceding consent statements. *

Conduct

Conduct
1. No students may drive to or during youth trips unless given prior permission by parents and youth group staff.
2. No student is allowed to go off by himself or herself.
3. Possession of tobacco, alcohol, illegal drugs, firearms, knives, or pornography will result in immediate dismissal from the event, which will require the student to be picked up from the event IMMEDIATELY by parents.
4. Cell phones may be collected on certain trips, but access to contact parents will be granted.
5. Medicines: Students are required to make staff aware of any prescription medications they may be taking.
6. We reserve the right to inspect bags and rooms of all students.
7. Members of the opposite sex are prohibited from entering each other's room, unless an adult is present and gives permission.
8. Proper modest attire must be worn at all times.
9. All students are required to participate.
10. Hopewell Church will not be responsible for incidental charges/damages to hotel rooms, or for personal property damaged or stolen while participating in youth activities.

Check that you have read and accept the preceding conduct statements. *

Electronic Signature: PRINT NAME BELOW to sign release. *

Hopewell Church
info@hwcf.org
610-286-6308