Student Ministries

What: NWMN Youth Conference

Where: Sun Dome in Yakima, WA
Cost: $115
Transportation: Church Vans
When: October 10 at 10am to October 11 at 10pm

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

______________ on ___________________ 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 _______ is $______. Make checks payable to Lake Stevens AG and write
“Youth Conference” and attending student’s name in the “for” column. Thanks! Phone: 360.273.8116
Fax: 360.858.1259.