Girl's Retreat: Healthy Bodies, Holy Lives

First Name: *

Last Name: *

Name of Health Insurance Provider and Policy Number: *

Special conditions, allergies, or medications:

Parent/Guardian Name(s): *

Parent/Guardian Phone #1: *

Parent/Guardian Phone #2:

Parent/Guardian E-mail: *

If parents cannot be reached, in case of emergency please contact:

Phone:

By checking the "Yes" box below, you give permission for your child to attend the Girl's Retreat "Healthy Bodies, Holy Lives" from April 25-27, 2014, and indicate that you understand that your child will be riding with an adult member of the congregation in their personal car. In the unlikely event of an emergency, if you cannot be contacted you give permission to Living Waters adult leadership to seek proper medical care. You also understand that photographs and videos may be taken of your child during church programming, and give permission for those photos/videos to be used for promotional or other purposes. *

Yes

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