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I give permission for my child to attend the Wildwood Discipleship Camp

with the Grace High School Ministry July 3-9, 2011. I give permission for medical
attention to be given to my child in the case of injury; including major surgery.
I understand that I will be contacted as soon as possible in the case of such an
accident. I release Grace Community Church and any other parties acting for the
church from liability in such a case. I request that the staff carry out any needed
discipline; if necessary, I will pay the expense of my child being sent home for an
extreme breach of the camp guidelines.

_______________________________________ _________________________________
Parent / Guardian Signature Date

Parent Email (must have to register) _____________________________________________

Student Name: ___________________________________________________________

Address: ________________________________________________________________

Birth Date: _____/_____/__________ Student Cell Phone (____) ______ - ____________

Home Phone: (_____) _____-___________________ Cell Phone: (_____) ________-____________

Emergency Contact: _______________________________________________________

Phone Number: (_____) _____-__________

Health Insurance Co. & Policy Number: ______________________________________________

Health Conditions / Allergies: _______________________________________________

Medications (Dosage): _____________________________________________________

T Shirt Size: ________

For any questions contact Phil de Martimprey, Youth Pastor

Phone: 562-522-1436 or email pdemartimprey@gmail.com