MUSLIM YOUTH OF GREATER PITTSBURGH

TRAVEL/STAY
PARENTAL PERMISSION & MEDICAL INFORMATION FORM

To Parents/Guardians:

This travel Permission/Medical Form will assure proper supervision for your child on MCCGP
Youth Group field trips/excursions.

The MCCGP Youth Group will be making a field trip/excursion to:

Seven Springs Mountain Resort
777 Water Wheel Drive
Seven Springs, PA 15622
(814) 352-7777
SEVEN SPRINGS MOUNTAIN RESORT 777 WATERWHEEL DR, SEVEN SPRINGS, PA
15622 814-352-7 The activity is under the supervision of the following volunteer
facilitators and Counselors:
Adult Supervisors: Riffat Chughtai, Shoaib Chughtai
Counselors: Sara Ayasoo, Sami Termanini, Omar Elhashmi, Louis El Hasmi
Date and Time of Arrival: 01/29/2011 1:00 pm
(date) (time)
Arrival at: M.C.C.G.P. 233 Seaman Lane, Monroeville PA 15146, 412-373-0101

Date and Time of Return: 01/29/2011 11:00 p.m..

(date) (time)
Pickup from: M.C.C.G.P. 233 Seaman Lane, Monroeville PA 15146, 412-373-0101

Arrangements: Transportation will be provided from and back to MCCGP. Children will have to bring
money for ski rental and lift tickets and $10.00 for Bus. They can also either
bring a packed dinner or money for it
Children should have appropriate ski clothing and have extra pair of socks and
gloves. Caps and goggles are a must
Please indicate below your approval for your child to participate in the field trip/excursion and return the
completed form via your child to the above designated person supervising the event.

Every precaution will be taken for the safety of your child but
we would accept your signatures as a release for MCCGP and the Youth Group from any liability in case of
injury or fatality occurring to your child
Please indicate any health
conditions:--------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------
Emergency Contact Person:
Name: --------------------------------------------------------------- Phone:------------------------------------------------

Health Insurance Name: ----------------------------------------------- Subscriber Name: ----------------------------

ID number: ------------------------------------------------------------- Group/Policy # ---------------------------------

I/We give permission to my child ____________________________

(youth’s name)
to participate in the above activity and release MCCGP and Youth Group from any liability.
 (Parent(s)/Guardian(s) signature(s)
“Children will not be allowed to participate without a signed permission slip by the parents/guardian.”