Reality Student Ministries

What: __________________________

Where: _________________________

Cost: __________________________

Transportation: __________________

When: _________________________

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 $________. Make checks payable to Lake
Stevens AG and write “(event name)” and attending student’s name in the “for” column.
Thanks! Questions? Contact Pastor Jeff at: Phone: 425.334.3700 E-mail:
Jeffandtiffgraham@yahoo.com