Permission Slip Camping Trip

Student Ministries What: Camping Trip Where: Schwendtkes Residence Cost: $5 Transportation: Church Vans When: September 12-13 (meet at the church at 5pm, we'll be back at the church at 10am for pickup) Personal Information* Name:_______________________________ Age:_____ Sex: M F (circle one) Address:_________________________________City:__________________________ State:_____ Zip:_________________ Phone:__________________________________ Date of Birth:________________

Parent’s Information* Name:_______________________________Phone:_____________________________ Address:__________________________________ City:_____________ Zip:________

Health Information* Are you in excellent health?________ If no, why?_______________________________ _______________________________________________________________________ Do you take any medication?________ If yes, please list:_________________________ _______________________________________________________________________ I, _________________________, give permission for ____________________ to attend the Back to School Camping Trip on Sept 12-13 with Reality Student Ministries, of Lake Stevens Assembly of God. I also give permission for any medical attention in case of accident, with the understanding that reasonable effort will be made to contact me immediately. I release Lake Stevens Assembly of God/Reality Student Ministries and agree to hold it harmless from any liability incurred from the above named minor in connection with the above described activity. ___________________________ _________ ________________ _________________ parent/guardian signature date cell phone emergency phone **IMPORTANT NOTE: Cost of the Back to School Camping Trip is $5. Make checks payable to Lake Stevens AG and write “Camping Trip” and attending student’s name in the “for” column. Thanks! Phone: 425.334.3700.