NEW CITY CHURCH YOUTH RETREAT
Event Timing: February 10-11, 2018
Meet at Church Offices 2/10, 9am
Returning to Church Offices 2/11, 3pm

Event Location: BigBear City, California
Contact us at 213-210-8802 or james@newcitychurchla.com
Cost: $30

Name *
Your answer
Email *
Your answer
Address *
Your answer
Grade
Your answer
Parent's Name
Your answer
Parent's e-mail
Your answer
Parent's Cell
Your answer
Dietary restrictions *
To whom it may concern
To whom it may concern:

The undersigned does hereby give permission for my child to attend and participate in the Retreat sponsored by New City Church

WE (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization (please check the appropriate box).

The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by New City Church

The undersigned understands that there are standards of behavior that is expected of our (my) child at this retreat, and if our (my) child exhibits behavior that is contrary to those standards, the Youth Pastor reserves the right to send our (my) child down from the retreat.

Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

Hospital Insurance
Insurance Company
Your answer
Policy Number
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of New City Church of Los Angeles. Report Abuse - Terms of Service - Additional Terms