8270 Buckingham Road, Fort Myers, FL 33905 (239) 791-8876
Generation Impact (G.I) Youth Ministry Activity Consent Forms
Students Name: __________________________________________ Date of Birth _____/______/______

Parent/ Guardian: _________________________________________ Are you attending this event?: YES NO

Address __________________________________ City_______________________ State_____ Zip___________

Parent Phone (Home) _________________________ (C) ______________________________

Parent (W) ________________ (Alt) __________________________

Student’s Cell Phone Number _____________________________________

Email address _________________________________________________________________________________

Does Your Child have Medical Insurance: YES NO (please circle one)

Medical/ Dental Provider ________________________ ____________________________

Date & Time: Saturday, November 15, 2014 – 11:00 A.M. – 11:00 P.M.

Logistics: Transportation via church van, departing from ACF parking lot at 11:00am.

I hereby give permission for _____________________________________ to attend the “Little Shop of Horrors”
with G.I Youth Ministry, Westcoast Black Theatre Troupe,1646 10
Way, Sarasota, FL 34236,
Fees: Adults $45, Teens $35. This includes lunch, ticket, and transportation. Payments received after Wednesday,
September 3, 2014 must include a $15 late fee

Medical restrictions Special considerations or restrictions: ____________________________

My Child has allergies to the following foods, insect bites or stings________________________________

Hold Harmless Agreement

I understand that participation in certain G.I activities can involve a certain degree of risk and can be
physically, mentally, and emotionally demanding. I have carefully considered the risk involved in this current
activity and have given consent for myself or my child to participate in this activity. I also understand that
participation in this activity is entirely voluntary and requires participants to abide by applicable rules and
standards of conduct. I release the Agape Christian Fellowship, G.I Youth Ministry, Youth Leaders, and all
ACF employees, volunteers and chaperones associated with the activity from any and all claims or liability
arising out of this participation.

In case of emergency involving my child, I understand every effort will be made to contact me. In the event I
cannot be reached, I hereby give my permission to the emergency medical provider selected by the adult
leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of
medication for my child. Medical providers are authorized to disclose to the adult in charge examination
findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up
and communication with the participant’s parent or guardian, and/or determination of the participant’s ability
to continue in the field trip activities.

Participant’s Signature: ________________________________ Date __________________________

Parent / Guardian Printed Name: ________________________________________________________

Parent / Guardian Signature: ___________________________ Date___________________________

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