Minors Permission & Medical Release | January 2026 - December 2026

Your name *

Email address *

Child's Phone Number

Address *

Parent/Guardian Email *

Parent/Guardian 1 Name *

Parent/Guardian 1 Cell Phone *

Parent/Guardian 1 Work Phone

Parent/Guardian 2 Name *

Parent/Guardian 2 Cell Phone *

Parent/Guardian 2 Work Phone

Emergency Contact

If person(s) named above is not available in the event of an emergency, notify:

Additional Phone Number

Medical Insurance Information

Medical Insurance Company *

Preferred Hospital *

Media Release

I grant Hessel Church the right and permission to use and publish the photographs/film/videotapes/electronic representations and/or sound recordings made of the Student named above at all Hessel Students events and activities, and I release Hessel Church, the activity coordinators, all employees, volunteers, related parties, or other organizations associated with the activity from any and all liability from such use and publication. I authorize the reproduction, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/film/videotapes/electronic representations and/or sound recording without limitation at the discretion of Hessel Church.

Media Release *

Yes

Events

The student named above has my permission to participate in any regular scheduled activities on Sundays and Wednesday evenings as well as any other events and trips occurring at Hessel Church, the local area and further areas in which camp and ministry trips are to take place during the dates stated.

Parent/Guardian Electronic Signature *

Email Permission

I grant Hessel Church permission to send email communications to the above email addresses regarding information pertinent to the events and activities sponsored by Hessel Students. I understand that personal information will be kept confidential and used solely for communication purposes. Although email is the main form of communication used by Hessel Student Ministries, I understand that I will have the option to opt out of email communication at any time.

Email Permission *

Yes

Medical Information

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this in the additional comments box below.

For your child's safety and our knowledge, describe your child's swimming abilities *

Does your child have allergies to: *

pollens

medications

food

insect bites

no known allergies

Other

Does you child suffer from, or has ever experienced , or is being treated currently for any of the following: *

asthma

epilepsy/seizures

heart trouble

diabetes

frequently upset stomach

physical handicap

none of the above

Does your child wear: *

glasses

contact lenses

hearing aids

none of the above

If you checked any of the above, explain:

What, if any, medication is your child taking?

Special instructions for medications?

Does your child have permission to be administered OTC medications as deemed necessary, by the leader? *

Please select one option.

Yes

Should the leader carry medication for your child? *

Please select one option.

Yes

If yes, please specify kind (i.e., ibuprophen, decongestant, etc.) and dosage

Date of last tetanus shot *

Should this child's activities be restricted for any reason? Please explain *

Please list and explain any major illnesses the child experienced during the last year

Code of Conduct

- No possession or use of alcohol, drugs, and/or tobacco
- Respect one another and the leaders
- No students can drive unless authorized
- Respect and comply with event schedules
- No fighting, weapons, fireworks, lighters, or explosives
- No boys in girls’ sleeping areas and no girls in boys’ sleeping areas
- No offensive or immodest clothing
- Participation with the group is expected
- Respect others

Students who fail to comply with these expectations may be sent home at their parents’ expense.

I, the student and parent/guardian, have read the rules of conduct, the above evaluation of my health, and permission to participate in Hessel Students activities. We agree to abide and stand by the stated personal limitations and code of conduct.

Student Electronic Signature *

Parent/Guardian Consent

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Hessel Church and its staff of any liability against personal losses of named child. I/We, the undersigned, have legal custody of the student named above, a minor; give my consent for him/her to attend events being organized by Hessel Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release Hessel Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my student’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event that treatment is required from a physician and/or hospital person- nel designated by Hessel Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/we also acknowledge that I/we 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/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our student home at my/our own expense should they become ill or if deemed necessary by the Hessel Church staff member.

Parent/Guardian 1 Electronic Signature *

Parent/Guardian 2 Electronic Signature