New Hope Medical & Liability Release Form 2023
Must be completed only once each year or when information changes.  Will apply for all children, youth, sponsors, etc. attending events and being transported, etc.  This will be used for all events in year 2023.
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Participant Name *
Gender *
Birthdate *
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Age
Best Contact Phone (for parent/guardian) *
Best Contact Email (for parent/guardian) *
Address (city, state, zip) *
Are immunizations current? *
Date of Tetanus Vaccination 
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List any allergies
List any regular medications taken and reason taken
List any health, growth, developmental conditions or special information the sponsor / leader should know to take care of your student and help them have a great event
Insurance Company Name *
Policy Number *
Group Number
Family Policy Holder Name *
Family Policy Holder Employer
Primary Doctor Name, Office Name, and Phone *
Please list the following below as parent/legal guardian to contact in case of emergency.  PARENT/GUARDIAN NAME, ADDRESS, CELL PHONE & 2ND PHONE NUMBER CONTACT.   *
Please list the following below as a second emergency person to contact in case of emergency.  NAME & RELATION, ADDRESS, CELL PHONE & 2ND PHONE NUMBER CONTACT. *
 In all cases, we will try and contact the parent/legal guardian and second emergency contact listed above first, but please know that in some cases, medical treatment may be necessary before a parent/legal guardian can be contacted.  Do you understand this policy. *
I release the leaders/sponsors to seek and provide any medical attention including, but not limited to dental, emergency, hospital, ambulance, doctor, etc. if needed, and I have legal authority to grant this right. By Typing my name below and saying "yes", I agree. *
The following individuals do NOT have permission to pick up my child, and my child CANNOT be released to the individuals listed below following events.
*I understand that if this form is not completely filled out, the individual above will not be allowed to participate in activities.  By typing my name below and saying yes, I agree. *
Events Acknowledgement: I understand that this form will cover all activities for the year 2022 sponsored by New Hope Christian Church.  It covers all Events specifically hosted and/or sponsored under New Hope Christian Church.  These events may be held at the church building, or at off-site locations.  I also understand that transportation may be given by others for the above individual to and from these events.  If, at any point, you do not grant release of liability for a specific event, you must present, in writing, prior to the event a written statement with signature.  By typing my name below and saying yes, I agree. *
I, the parent or legal guardian of the child/youth listed on this form, or the sponsor/adult attending, certify that the above named person has my full permission and approval to participate in the above activities and programs.  (If from a divorce/separated relationship, I also certify that I have legal authority to sign this form for the youth/child.)  I release and agree to indemnify and hold blameless from bodily injury or death, New Hope Christian Church and others not limited to, but including its’ staff, sponsors, leadership board, volunteers, and transportation drivers from any claim arising, or which may be asserted by me, my child, or by any other family member, relative, or friend by reason of participating in the activities and programs.  I also agree myself, my child, nor any family member, relative, or friend will not hold liable any property owners (Home or Vehicle) associated with New Hope Christian Church including but not limited to its staff, sponsors, leadership board, or volunteers that may be associated with this activity.   I understand that rules will be laid out before the activity or event begins.  These rules are given for the safety of all individuals attending. For Parents of Children/Youth:  It is my child/youth’s responsibility to listen to and obey all rules given.  I understand that any breaking of rules could result in my child/youth being sent home.  If my child/youth is sent home, I will agree to pick up my child/youth in a timely manner at a location convenient to the sponsor(s) that is responsible for or assisting with the above activity. This may mean picking up my child/youth at the activity location, itself.  My child/youth and I have read this form, and he/she understands his/her responsibilities and agrees to obey all rules.   I understand photos and/or videos may be made with the above named individual to post on our website, social media, advertisements, promotions, videos, etc., and I give my permission and consent to publish. As parent of a child/youth attending or if the Sponsor attending, I have asked all questions I have about the activity and am satisfied with the answers.  I understand and agree to all risks that may occur by participating.  I further state that I have carefully read the foregoing release and know the contents thereof, the rules, and I sign this release as my own free act and in sound mind.  This is a legally binding agreement, which I have read and completely understand.    By typing my name below and saying yes, I agree. *
Date Form Completed *
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For verification purposes, please state the following answers for the person filling out and signing yes on this form.  SIGNEE BIRTHDATE (month, date), SIGNEE MIDDLE NAME *
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