For:________Senior High Ministry @ Calvary Chapel of Delta_____________________

Event: CREATION 2011 Northeast

Location: AGAPE FARM - Mt. Union, PA

Date: June 29th – July 2nd

Time: Wednesday Morning, June 29th @ 9am we will meet for departure from Calvary Chapel
we will be returning late Saturday evening. Those needing to be picked up by parents will
be responsible to call and notify them of an estimated arrival time back at Calvary Chapel______

Other Information: additional information is provided on a separate handout

Respond to let us know you are coming by: ________Sunday, May 1st, 2011___________

For More Information Contact: Josh Harris – (church)1-717-456-7600 (Cell) 717-873-3797

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Calvary Chapel of Delta
PARENT PERMISSION – RELEASE FORM

Event/ Location: _________________________________________________

Date: __________________________________________________________

I, ______________________________________________, give my permission for my

child(ren) ______________________________________________________________ to
participate in the above activity. I also give my permission for my child to carpool with other adult volunteers to
and from this event. I release Calvary Chapel of Delta, its Agents, Leaders, and Volunteers from any liability claim
of property loss or damage, and from any claim of personal injury to my child(ren) while taking part in the above
activity. I also release the adult drivers and the property owners of the property where the event shall take place from
any liability claim of property loss or damage, and from any claim of personal injury to my child(ren) while taking
part in the above activity.
In the event of an emergency, I hereby authorize an adult leader of this activity, as agent for me, to consent to any
X-ray examination; medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a
physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are
rendered, either at a doctor's office or in any hospital. I expect to be contacted as soon as possible.

In addition- I hereby agree to pay the full cost of $99.00 for the Creationfest 2011 ticket (per child).
This is a written commitment to pay the price of the ticket (per child) regardless of negligence to attend, or if
disciplinary action forces the child or children to leave the event before its conclusion.
I have read and understand the “Campsite Code of Conduct” and “Consequence for Misconduct” handouts.

Unless otherwise noted, you have my permission to give my child the following over the counter medications
if needed per the instructions on the medication: Tums, Tylenol, Ibuprofen, cough drops, or Benadryl.

Medical concerns or allergies: Medications being taken:

Emergency Contact: Physical Handicap or limits

Phone(s) Medical Insurance Co.

Policy # Member Name

PARENT SIGNATURE __________________________________________________

Date ______________________________________