9-12TH GRADE

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January 29-31, 2010

Jeff Dean
For added
Attaboy fun…
$125 ($50 deposit & form due by Bring all y
our
January 17) friends!!

I, ________________________________(parent/guardian), give permission for _________________________________(student)

to take part in the SpringHill Winter Retreat including, but not limited to transportation and activities, on January 29-31, 2010. I understand
the nature of the event and do hereby release Mount Pleasant Community Church, its employees, staff and volunteers from all liability or
claims arising from or related to the event. In the event of an emergency, I hereby authorize an adult leader of this activity, as an agent for
me, to consent to any X-ray examination; medical, dental or surgical diagnosis; treatment; and or 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.

Home Phone: _________________________ Mobile Phone (parent): ____________________________

Address: ___________________________________________________________ Grade of Student_____

Parent/Guardian Signature: _____________________________________________ Date: _____________

C
Office use only: Deposit Cash Check # Balance