Save the date
Spring retreat March 4-5 at Heartland Center
2017 Youth tubing rally
Registration deadline
Friday, January 6
Beginning with mixers, worship, and lunch at Pine Ridge Presbyterian Church and concluding at Snow Creek Ski Area, for Heartland Presbytery youth and their chaperones.
$40 covers tubing ticket, lunch, and snack after tubing.
Please bring a permission slip for each person and give it to your responsible adult. If needed, the presbytery can email you a blank form, or if your church uses a similar form, just bring it.
HEARTLAND PRESBYTERY’S YOUTH RETREAT
PERMISSION FORM
Winter tubing event
Name
of Youth:________________________________________________________________
First Middle Last
Home
address:_________________________________________________________________
Street
address city/state/zip
Youth
cell phone #:________________________ Grade in school:_______________________
Parent/Guardian
name_________________________Cell phone #______________________
Parent/Guardian
name_________________________Cell phone #______________________
Emergency
contact name and # (other than parent):_________________________________
______________________________________________________________________________
Medical Information
Please list any allergies:_________________________________________________________
_____________________________________________________________________________
Medical/emotional/mental/other conditions of which leaders should be
aware:________________________________________________________________________
Medications requiring special dispensing/storage:___________________________________
Primary Physician’s Name and #:_________________________________________________
Health Insurance (name of insurer)_________________________Policy #________________
By signing below, I give consent for my child to participate in this event. I also give my child permission to be given medical treatment, medical assistance, assessment and surgery or life saving measures if needed.
Signature ________________________________________________________
Relationship to child ________________________ Date _________________________