Dear Parent/Legal Guardian,

Your son/daughter has shown an interest in participating in World Vision’s 30 Hour Famine with Grace Chinese
Lutheran Church and NY Dong Yang First Church, and The Reformed Church of Newtown.

Participation means that your son/daughter will:

• Sign up 30 Hour Famine sponsors and collect money to help those around the world who suffer from hunger,
poverty, and a lack of hope.
• Miss three main meals by fasting for 30 hours. (Fasting period: 9am- Friday, June 16th – 3pm, Saturday, April 17th,
2006.)
• Attend the 30 Hour Famine hosted by the churches. Registration begins at 5pm on Friday, June 16th in The
Reformed Church of Newtown.
• Drink only water and juice during those 30 hours.
• Turn in the Famine Survival Guide and money raised to his or her Famine leader during the Famine event.
• Participate in the games, activities, bible studies, and sessions for the event.

Thank You,
The 30 Hour Famine Leadership Team of Grace Chinese Lutheran Church

More than half a million teens nationwide will participate in the 30 Hour Famine this year. Last year, $11.6 million
was raised, contributing to World Vision’s response in countries worldwide where famine, conflict, and other crises
make children vulnerable to hunger and preventable disease.

World Vision is a Christian relief and development organization dedicated to helping children and their communities
worldwide reach their full potential by tackling the causes of poverty. Motivated by our faith in Jesus, we serve the
poor as a demonstration of God’s unconditional love for all people – regardless of a person’s religion, race, ethnicity,
or gender.

Fasting is a physical benefit for most people. Exceptions are children under 12 years of age, the elderly, diabetics,
those pregnant or nursing, and others who have had recent surgeries or have other specific medical problems. Most
youth will have no problems completing the 30 Hour Famine; however, modifications can be made as necessary. If
you have any health-related questions about your child’s participation in the Famine, please consult your doctor.

For more information on fasting, you can request a “Facts on Fasting” sheet from your Famine group leader. You can
also obtain this sheet by calling 1-800-7-FAMINE or finding it at www.30hourfamine.org. Please do not send this
consent form to World Vision.
-----------------------------------------------------------------------------------------------------------------------------------------------------------
Contacts:
Grace Chinese Lutheran Church: 43-33 91st Place; Elmhurst, NY 11373
Pastor Abraham Lu or David Song: Tel: (718) 760-4132; Fax: (718) 750-1375

Event Location:

NY Dong Yang First Church 50-43 97th Place; Corona, NY 11368

The Reformed Church of Newtown 85-15 Broadway; Elmhurst, NY 11373
Please refrain from calling your child during the event as it may disturb the flow of
activities.
 World Vision’s 30 Hour Famine Kick Off
Event
EVENT, HEALTH, RELEASE AND PERMISSION FORM
Name of Participating Groups: Grace Chinese Lutheran Church, NY Dong Yang First Church & The
Reformed Church of Newtown
Date of Event: Friday, June 16th, 2006; 5pm – Saturday, Aprilth, 2006 5pm .
Location of Event: NY Dong Yang First Church 50-43 97th Place; Corona, NY 11368 , The Reformed Church of .
Newtown & Outdoors of Church Vicinity .

Name of Youth Participant: ___________________________________________________ Age: ________ Gender: M or_ F_

First MI Last Age Circle One

Birth date: _______________________ Grade: ________________________ Home Phone # _________________________________

Month/Day/Year
Parent/Legal Guardian: _________________________________________________________________________________________

Home Address: _______________________________________________________________________________________________

Street City State Zip

Second Parent or Emergency Contact Person: _____________________________________________________________________

Address: __________________________________________________________________________________________________________
Street City State Zip
Phone: __________________________________________
Name of Youth’s Doctor: _________________________________________ Phone: _____________________________________________
Address/ City: _____________________________________________________________________________________________________
Parent/ Guardian’s Insurance: _________________________________________________________________________________________
Name of Parent Listed on Insurance: ___________________________________________________________________________________
Policy or Group Number: ____________________________________________________________________________________________
Indicate current medical treatment: _____________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Please send any medications in original containers. An adult from the group will be responsible to dispense and keep medications.
List any allergies, dietary concerns, or medical conditions:
______________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________

Permission:
I hereby give permission for my son/daughter/legal ward to participate in all event activities. Further, I give permission for use of photos of
my son/ daughter to be used in event promotion unless noted. My son/ daughter will follow the rules of the event and the directions of the
staff.
Release of Liability:
I hereby give permission for Grace Chinese Lutheran Church, NY Dong Yang First Church & The Reformed Church of Newtown through its
employees or agents to provide or arrange the necessary medical assistance for my son/ daughter/ legal ward if I cannot be immediately
reached, with the understanding that I will not hold Grace Chinese Lutheran Church, NY Dong Yang First Church & The Reformed Church
of Newtown, or its employees, agents, or representatives responsible for the actions of the agents, representatives, or employees of the
medical facility. I will also assume any and all responsibility for payment for the same. I understand that my son/daughter/legal ward is
responsible for his/her actions and behavior at all times. If he/she breaks any rules, it is my responsibility to pick him/her up at the event site.
By signing I hereby release Grace Chinese Lutheran Church, NY Dong Yang First Church & The Reformed Church of Newtown and its
officers, agents, employees, successors, and assigns from any and all liability arising out of or in any way related to participation in this event.
Authorization for Treatment:
I hereby give permission and authorize an adult, in whose care my son/daughter/legal ward has been entrusted, to consent to any x-ray
examinations, anesthetics, medical, surgical or dental diagnosis or treatment, routine tests, hospital care, and necessary transportation to be
rendered to the minor under the provisions of the Medical Practice Act on the medical staff of a licensed hospital.. In the event I cannot be
reached in an emergency, I give permission to the physician selected by the Grace Chinese Lutheran Church, NY Dong Yang First Church &
The Reformed Church of Newtown and its officers, agents, employees, successors, and assigns to secure and administer treatment, including
hospitalization, for my son/daughter/legal ward as named above.
Signature of Parent/Guardian: ______________________________________________________
Date: ______________________

30 HOUR FAMINE
2006
LIST OF THINGS TO BRING TO THE FAMINE EVENT

Please check off the items as you pack

1 Backpack with the items below (you don’t need a suitcase, ladies)
 30 HF shirt/Orange Shirt/something obscenely Orange/
 Scarf/bandana
 Clothing
o 1 set of clothing for Saturday (shirt, pants, undergarments, socks, etc.)
o extra pair of socks

o 1 long sleeve shirt/hoodie (incase it gets cold)

 1 Face Towel

 Toothbrush & Toothpaste

 Brush/Comb
 Toiletries
o Facial Cleansers
o Girly Hygienic Stuff

o Deodorant… PLEASE!!! 

 Plastic Water Bottle (Nalgenes, Poland Springs Bottle, etc.)

 Alarm Clock/Watch
 Bible, Pen, Notepad

 Medication, if you take any

 Camera (digital would be great, but single uses and manuals are good as well. If you can, please
also bring necessary cables/devices to upload on the computer)
 Tissue
 Sleeping Bag
 FLASHLIGHT!!! (We’ll be playing a game that requires that)

 Please wear closed toe shoes (sneakers, boots), we will be

playing games that might require stomping… and if you wear flip flops, you’ll lose a few toe claws.
 NO FOOD!!!

Please do not bring any valuables to the event.

The employees, agents, staff and counselors of
Grace Chinese Lutheran Church, NY Dong Yang First Church and The Reformed Church of
Newtown will not be responsible for any lost or stolen items.