Permission Slip Youth Conference

Student Ministries What: NWMN Youth Conference Where: Sun Dome in Yakima, WA Cost: $115 Transportation: Church Vans When: October 10 at 10am to October 11 at 10pm 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 ______________ on ___________________ 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 _______ is $______. Make checks payable to Lake Stevens AG and write “Youth Conference” and attending student’s name in the “for” column. Thanks! Phone: 360.273.8116 Fax: 360.858.1259.