Laurelville Mud Weekend HS Retreat - Parental Permission Form
Laurelville Mud Weekend High School Retreat
Time and Place of Departure: Bellefield Church, Friday November 22, Time TBD

Time and Place of Return: Bellefield Church, Sunday November 24, Time TBD

Mode of Transportation: Carpool with Trip Leaders

Items Needed for Activity: See Separate Packing List

Form Due By: Friday November 1, 2019

Payment Amount Due: $50 per child/$100 family max due in full by Friday November 1, 2019
Parental Permission
By completing this form for Bellefield Presbyterian Church, I hereby give my permission for my child(ren) to attend and participate in the Laurelville Mud Weekend High School Retreat.
Please List Child(ren) Attending *
Your answer
Please List Child(ren)'s Age(s) and Grade(s) *
Your answer
To the best of my knowledge, my child(ren) is/are in good health and free of illness at this time *
I give permission for my child(ren) to be photographed for print, digital or electronic images. These images 
may be used by the church or the youth group in print or online format. *
Please list any serious health problems or allergies that may affect your child(ren) during this activity: 
 *
Your answer
Parental Contact Info
Primary Phone *
Your answer
Secondary Phone
Your answer
Email Address *
Your answer
Emergency Contact Info
If I cannot be reached in the event of an emergency, the following person is authorized to act on my behalf. Please make sure this person is aware of the date and time of the activity.
Name *
Your answer
Relation to Youth *
Your answer
Phone *
Your answer
Youth Pick-Up
Who will pick up your child(ren) after the Laurelville Mud Weekend High School Retreat?
Name *
Your answer
Relation to Youth *
Your answer
Medical Information
Health Insurance Carrier: *
Your answer
Group or ID # *
Your answer
I authorize [Trip Leaders] to take my abovementioned child(ren) to the hospital should emergency treatment be necessary. *
Please List any Allergies
Your answer
Please List any Dietary Requests (vegetarian, gluten-free, etc.)
Your answer
Please List any other Physical Limitations and/or Special Instructions
Your answer
Final Signature
By completing this form for Bellefield Presbyterian Church, I hereby give my permission for my child(ren) to attend and participate in the Laurelville Mud Weekend High School Retreat.

I understand that by typing my full legal name below that I am authorizing my digital signature as my legally binding signature.
Signed By *
Your answer
Date *
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