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600 West New Hope Dr. | Cedar Park, TX 78613
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New to Highpoint?
2018-2019 HPY Registration/Permission Form
Thank you for encouraging your student to attend a Highpoint Youth event or trip!
Select your trip
MS CIY:Believe (Dallas, TX) - Oct 19-20
HS Fall Advance - Nov. 2-4
MS/HS Mid-Winter Retreat - Jan 25-27
Participant First Name
Participant Last Name
Participant Phone (or N/A)
Shirt Size (note: not every activity/trip will have a shirt)
Parent First and Last Name
Parent Phone Number
Emergency Contact Info (Name & Number)
Will your student need to take medications on this trip?
Please ensure that medications are in a ziplock bag, labeled with the students' name. Dosage information should be included on the label or within the bag. Give to designated youth sponsor in attendance of event.
Known Allergies and Reactions
Do you have personal health insurance?
I certify I DO have personal health insurance, with no territorial limitation, for the providing of medical services to me (and my child)which will provide coverage for my child during the duration of said trip. I understand that HighPoint Fellowship provides no health plan.
Yes, I do have personal health insurance
I certify I DO NOT have personal health insurance. I understand that I am responsible for any and all medical expenses incurred during theduration of said trip. I also understand that HighPoint Fellowship provides no health plan.
I certify I do not have personal health insurance.
Physician Name and Phone Number
Insurance Company Phone Number
Authorization: The above named sudent wishes to be a participant on a Highpoint Fellowship trip which will be traveling off the Church property and WHEREAS, certain circumstances may occur resulting in my child’s need for medical/dental care and treatment, and further resulting in my inability to personally give consent for such care and treatment; THEREFORE, In consideration of permission from Highpoint Fellowship for my child to participate in said trip. I authorize Highpoint Fellowship to consent to all medical and/or dental care and treatment, including but not limited to diagnostic test, x-ray, examination, anesthesia, surgery, or other procedures which Highpoint Fellowship deems necessary for my child’s medical well-being for the duration of the trip. This consent is given in advance of any specific diagnosis, treatment, surgery, or hospital care required and to the administration of any over the counter medications including but not limited to Tylenol, Advil, Tums, Immodium, Pepto Bismol, and allergy medications, and is given to provide authorization and specific, consent for medical/dental treatment and care in my behalf. Any consent by Highpoint Fellowship shall have the same force and effect as if I had personally given the consent. I do for myself understand that trip activities may involve physical exertion and effort, and for and on behalf of my child do hereby release, forever discharge and agree to hold harmless Highpoint Fellowship and the directors/officers thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child that occur while said child is participating in trip activities. Furthermore, I (and on behalf of my child) hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in activities involved therein. The undersigned further hereby agree to hold harmless and indemnify said organizations, directors, employees and agents, for any liability sustained by said organizations as the result of the negligent, willful or intentional acts of said child, including expenses incurred attendant thereto. I also give permission for Highpoint Fellowship to use all photographs, videos, and/or sketches of my child in print material, video, and on the internet.
I have read the Authorization and agree to the terms.
On your touchscreen device or with your mouse, please enter your signature here.
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600 West New Hope Dr | Cedar Park, TX 78613 | Phone: 512.260.5449