I.M.P.A.C.T.

YOUTH MINISTRIES

PERMISSION SLIP/MEDICAL RELEASE

Power of One – Saturday, November 10, 2007 – Green Bay, WI

NAME:____________________________________________________ AGE:________

ADDRESS:_________________________________________________ CITY:______________________

HOME TELEPHONE:_______________________ BIRTHDATE:_____________

WE WILL BE LEAVING FROM THE SPIRIT TOWN HALL @ APPROX. 7 A.M. SAT. MORN. & WILL BE RETURNING @
APPROX. 1:30 A.M. SUNDAY MORNING.
WE WILL BE TAKING VANS WITH DRIVERS OVER 21 YRS. OLD

In the event of an emergency where medical treatment is required, I give my permission to the leaders of Impact
Youth Ministries to obtain the services of a licensed physician. I further agree to indemnify Impact Youth Ministries and its
leadership, for any and all damage or injury that my child may acquire resulting in his/her participation in this event. I release
and waive any liabilities against Impact Youth Ministries, its employees, leaders, and volunteers. I acknowledge that these
activities may include but are not limited to activities during day or evening hours, requiring transportation by motorized
vehicles and occasionally may involve overnight stays. We will not hold any other organizations liable as it pertains to these
trips.

Person to notify in case of Emergency:___________________________________ Number:_______________________

Parents' Name(s):______________________________________________________________________

INSURANCE PROVIDER:_____________________________________________________

POLICY NUMBER:__________________________________________________________

Signature of Parent or legal guardian:____________________________________ Date:__________________

*** Please list anything that might limit your child from participating in activities as well as any allergies or medical needs
What: Power
including of One ‘07that may be needed on activity on backside. If you do not want your child/teen participating in particular
medication
activities (i.e. jumping on trampoline) please list that as well.
Where: Resch Center, Green Bay, WI

When: 7am Saturday – 1:30 am Sunday November

Parents 10 & 11is for you to cut off and keep.
– This
Why: To have fun in a positive atmosphere with the latest Christian If you have any ?’s - Please contact:
bands, growing in our relationship with Christ and each other.
Eric Gladson – 715.612.2015 or ericgladson@mac.com