Uprising Event Permission Slip

The Uprising Student Ministry Gateway Community Church, Austin, TX.

Event Application Event: Uprising Half Niter Date: November 14th 2008 Event Details: Students will travel in school bus to Austin Park and Pizza as well as Recreation Center Cost: $25.00 Application Due Date: November 14th Please make Cheques payable to: Gateway Community Church

Student Information First Name: Age Email: City

Last Name: Grade: Phone: Address: Postal Code: Name(s): Home Phone:

Please submit form & money to: Front Office or Check-in Team

Gender: M | F

Parent / Guardian Information Email: Other Phone:

Health Card #: Medical Conditions or Allergies: (Please make special note of food allergies)

Medical Information Health Card Expiry Date: Medication(s) Currently Being Taken: (Please note medication names and times taken)

Permission Form Parent I / we are the legal guardians of the student named above and hereby give my / our permission for the named student to participate in the above named event with the leaders of the Uprising/ Gateway Community Church. I understand that in the event of an emergency that the leaders of the Uprising/ Gateway Community Church will do everything in their power to contact me personally, but that in the event that they are unable to do so, I / we give my / our permission for the leaders to seek necessary medical attention for the student named above.

Signature: Approved (Circle One): Yes / No

Date: Office Use Only Paid:

Owed:

Gateway Community Church, 7104 McNeil Drive, Austin, TX 78729, 512 837 2162