HHMC Youth Participation Form and Medical Release 2025-2026
An online medical release form for students to participate in Harker Heights Methodist Church Student Ministry (HHMC Youth). A new form must be completed each year.
Student's Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Female
Male
Grade:
*
(2025-2026 School Year)
School:
*
Cell Phone Number:
*
-
Area Code
Phone Number
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent / Guardian Information:
Parent / Guardian Name:
*
First Name
Last Name
Cell Phone Number:
*
-
Area Code
Phone Number
Parent E-mail:
*
example@example.com
Parent / Guardian Name:
First Name
Last Name
Cell Phone Number:
-
Area Code
Phone Number
Parent E-mail:
example@example.com
Emergency Contact (If parents cannot be contacted)
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
We will use Flocknote to communicate upcoming events and important information via text. Text "HHMCYOUTH" to 84576 to enroll.
*
yes, I am enrolled in flocknote
no, I am not yet enrolled in flocknote but plan to do so
Student Medical Information:
Medical Insurance Company:
Please enter None if you don't have insurance at this time.
Med Ins. Policy #:
Please enter None if you don't have insurance at this time.
List any allergies your student has:
EpiPen
yes
no
Student's Date of last tetanus shot:
-
Month
-
Day
Year
Date
My student has my permission to attend youth activities sponsored by Harker Heights Methodist Church (hereinafter “HHMC”).
I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by HHMC. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release HHMC, 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/our child’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 treatment is required from a physician and/or hospital personnel designated by HHMC, 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 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 child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member. I/We hereby grant permission for my child to participate in HHMC sponsored activities. I/We are aware that photos or video may be taken of HHMC Youth participants during events, activities, and classes by HHMC staff, professional photographers, or volunteers. I/We also understand that my child is not required to have his/her picture taken. I waive the right to see or approve any publications that contain legal photographs of my child. I give HHMC permission to use photographs or video that include my child in any and all media products for promotion, art, advertising, editorial, or other purpose. This may include but is not limited to newsletters, both print and email, posters, brochures, ads, postcards, and web pages. BY SUBMITTING THIS FORM I AGREE TO THE AFOREMENTIONED TERMS AND STIPULATIONS.
Submitted Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: