Youth Conference Permission Slip

Reality Student Ministries What: Youth Conference Where: Yakima, WA Cost: $115 Transportation: Church Vans When: October 99-10, 3pm to 9pm 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 this event 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 this event is $115. Make checks payable to Lake Stevens AG and write “Youth Conference” and attending student’s name in the “for” column. Thanks! Questions? Contact Pastor Jeff at: Phone: 425.334.3700 E-mail: [email protected]