Schools Out Permission Slip
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Reality Student Ministries What: School’s Out Party Where: Chuck and Kippy Wolff’s House Cost: Free Transportation: Church Vans When: June 17th from 6-8:30 pm Personal Information Name:_______________________________ Age:_____ Sex: M F (circle one)
What: School’s Out Party Where: Chuck and Kippy Wolff’s House Cost: Free Transportation: Church Vans When: June 17th from 6-8:30 pm Personal Information Name:_______________________________ Age:_____ Sex: M F (circle one) Address:_________________________________City:__________________________
Address:_________________________________City:__________________________
State:_____ Zip:_________________ Phone:__________________________________
State:_____ Zip:_________________ Phone:__________________________________
Date of Birth:________________
Date of Birth:________________ Parent’s Information Parent’s Information
Name:_______________________________Phone:_____________________________
Name:_______________________________Phone:_____________________________
Address:__________________________________ City:_____________ Zip:________
Address:__________________________________ City:_____________ Zip:________ Health Information Health Information
Are you in excellent health?________ If no, why?_______________________________
Are you in excellent health?________ If no, why?_______________________________
_______________________________________________________________________
_______________________________________________________________________
Do you take any medication?________ If yes, please list:_________________________
Do you take any medication?________ If yes, please list:_________________________
_______________________________________________________________________
_______________________________________________________________________ I, _________________________, give permission for ____________________ to attend the School’s Out Party on June 17, 2009 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 Questions? Contact Pastor Jeff at: Phone: 425.334.3700 E-mail: [email protected] or go online to www.realityyouthonline.com
Reality Student Ministries
I, _________________________, give permission for ____________________ to attend the School’s Out Party on June 17, 2009 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 Questions? Contact Pastor Jeff at: Phone: 425.334.3700 E-mail: [email protected] or go online to www.realityyouthonline.com
What: School’s Out Party Where: Chuck and Kippy Wolff’s House Cost: Free Transportation: Church Vans When: June 17th from 6-8:30 pm Personal Information Name:_______________________________ Age:_____ Sex: M F (circle one) Address:_________________________________City:__________________________
Address:_________________________________City:__________________________
State:_____ Zip:_________________ Phone:__________________________________
State:_____ Zip:_________________ Phone:__________________________________
Date of Birth:________________
Date of Birth:________________ Parent’s Information Parent’s Information
Name:_______________________________Phone:_____________________________
Name:_______________________________Phone:_____________________________
Address:__________________________________ City:_____________ Zip:________
Address:__________________________________ City:_____________ Zip:________ Health Information Health Information
Are you in excellent health?________ If no, why?_______________________________
Are you in excellent health?________ If no, why?_______________________________
_______________________________________________________________________
_______________________________________________________________________
Do you take any medication?________ If yes, please list:_________________________
Do you take any medication?________ If yes, please list:_________________________
_______________________________________________________________________
_______________________________________________________________________ I, _________________________, give permission for ____________________ to attend the School’s Out Party on June 17, 2009 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 Questions? Contact Pastor Jeff at: Phone: 425.334.3700 E-mail: [email protected] or go online to www.realityyouthonline.com
Reality Student Ministries
I, _________________________, give permission for ____________________ to attend the School’s Out Party on June 17, 2009 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 Questions? Contact Pastor Jeff at: Phone: 425.334.3700 E-mail: [email protected] or go online to www.realityyouthonline.com
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