Permission Slip

Please fill out completely and return with deposit to Ben Vogler on or before October 16, 2013
has my permission to participate in the Fall Retreat at The Summit with Emerywood Baptist Church on November 22-24, 2013. I release Emerywood Baptist Church and the trip sponsors and/or chaperons from liability for injury or accident (except as may be incurred while riding as a passenger in a church owned vehicle), and do give my permission to chaperons to secure proper medical attention should the need arise.

Parents Signature

Date

Student Information
Date of Birth: Address: Parents Name: Fathers Work Phone: Mothers Work Phone: Church Affiliation: Family Physician: Insurance Company and Policy Number: I give my permission for my childs likeness to be submitted in promotional videos or social medias regarding this retreat Yes: _____ NO: ______ Phone: Home Phone: Home Phone: Age: Grade In School : T-Shirt Size

Youth Personal Covenant

While attending this activity, I agree to: 1. Attend and be on time for every session. 2. Take part in the activities as far as possible 3. Support others in the group in their participation 4. Be responsible for my actions and not jeopardize my safety or that of others.

Student Signature / Date

Medical Information
Yes
Know how to swim Permission to swim Tetanus shot up to date Any reaction to penicillin Any reaction to insect bites Asthma Sinus Problems Ear Infection Weak Heart Any medications to be taken regularly (Give details in Remarks section below) Any reactions to drugs (Give details in Remarks section below) Any physical handicaps (Give details in Remarks section below) Any reaction to sun or sunburn

No

Please list all allergies:

Remarks Section: