Permission Form

New Hope Leeward EPIC High School Ministry

--HALLOWEEN NIGHT EVENT-Parental Consent Special Event Form Student Information

Emergency Notification

Name:__________________________________

Emergency Contact:_____________

Address:________________________________

Home Phone:__________________

City & State:_____________ Zip____________

Work Phone:___________________

E-Mail:_________________________________

Insurance Company_____________

Phone: _________________________________

Policy #_______________________

Birth Date:________________ Sex:__________ The EPIC Halloween Night Event is a joint venture with New Hope Oahu’s High School Ministry. Cost is $5 per person and covers bus transportation to and from the Leeward Ministry Center and food. Signed permission form is required to attend, cost does not change if you do not ride the bus. Questions? Call Jamie at 779-4447.

Allergies and Health History Please list any allergies and any other special medical conditions the student may have: _____________________________________________________________________________ I, _________________________(parent or guardian print name) hereby acknowledge that it is my desire (for my child) to participate in The EPIC Halloween Night Event on Wednesday October 31, 2007 as a church-sponsored event of New Hope Leeward and New Hope Oahu, including activities on and/or away from the church premises as well as transportation to and from such activities. I AM (MY CHILD) VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES, INCLUDING TRANSPORTATION TO AND FROM SUCH ACTIVITIES, WITH KNOWLEDGE OF THE DANGERS INVOLVED AND HEREBY AGREE TO ACCEPT ANY AND ALL RISK OF INJURY AS A RESULT OF SUCH PARTICIPATION AND TRANSPORTATION. As lawful consideration for permitting me (my child) to participate in such activities, including the transportation to and from such activities, I hereby release and discharge New Hope Leeward, New Hope Oahu, its officers, employees, agents and members of the Church Council from all actions, claims or demands I and my heirs, distributes, guardians, legal representatives or assigns now have or may hereafter have for any injury or damages resulting from the negligence or other acts, howsoever caused, by such church, officers, employees, agents and Church Council, before or during my participation in such church sponsored activities on and/or away from the church premises, including transportation to and from such activities. I HAVE CARFULLY READ THIS AGREEMENT AND UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND AN ASSUMPTION OF RISKS AND SIGN IT OF MY OWN FREE WILL.

Parent/Guardian Signature

Date

Student Signature

Date