October 2011
Palisades Youth Group
PLEASE INITIAL WHICH EVENT(S) YOU WILL BE ATTENDING.
_______ OCT 22 (SAT) HARLEM EXPLORERS COMMUNITY SERVICE
Depart church 9:30 AM
Arrive church 2:30 PM
*prep meeting is Friday (Oct 21)
_______ OCT 28 (FRI) Fellowship: Rock Climbing at Gravity Vault (Upper Saddle River, NJ)
107 Pleasant Ave (Rt. 17), Upper Saddle River, NJ TEL 201.934.ROCK (7625)
Depart Church: 7:30 PM
Arrive Church: 10:30 PM
Fee: $25/person - Includes Climbing Fee, Rentals, Food(Pizza)
**IMPORTANT: Must also bring Gravity Vault WAIVER (4-page document) Please download from church website or PYG Blog
Any questions? Contact Pastor Rana 213.500.3750 or Pastor Paul 201.638.2507
(Please return this lower portion to Palisades Church)
Student Information
Name: ____________________________
Grade: _____ Gender: M F
Please state any physical handicap, allergies, medication or restrictions:
________________________________________________________________________
Is the student allergic to any medicines?
In case of emergency, parent or guardian can be reached at:
Name:_____________________ Phone: (______)_________________
As the parent or guardian of the student mentioned above, I hereby grant permission of attendance as well as authorize the staff to make any necessary decisions in case of emergency and will be responsible for any expenses.
Parent/Guardian Name: ____________________________________
Signature: _________________________________ Date: _____________
****We need chaperones/drivers for Harlem or Rock Climbing (Circle). Please volunteer
YES, I can chaperone/drive for this event.
Which event?___________________________
Chaperone Name: ____________________________
Primary Phone Number: __________________________