Student Ministries

What: Camping Trip

Where: Schwendtkes Residence
Cost: $5
Transportation: Church Vans
When: September 12-13 (meet at the church at 5pm, we'll be
back at the church at 10am for pickup)

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

the Back to School Camping Trip on Sept 12-13 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 the Back to School Camping Trip is $5. Make checks payable to Lake
Stevens AG and write “Camping Trip” and attending student’s name in the “for” column. Thanks! Phone:
425.334.3700.