Youth Name: ________________________
Email Address: ___________________________
Grade: _________ Congregation (if applicable):
_____________
Email ________________________________
I promise to live by the rules and to actively
support the program developed by the staff.
__________________________________
Signature of Youth
Parent/Guardian, Please Sign
I give my permission for ___________
to
attend the Chicago Mission Center Youth Retreat, having confidence that those
in charge will exercise diligence for the safety of the youth. I hereby release
the leaders of any responsibility for personal injury.
IN CASE OF EMERGENCY I understand that every effort
will be made to contact the parents or guardians of the youth. In the event
that I cannot be reached, I hereby give my permission to the physician selected
by the youth director to hospitalize, secure proper treatment for, and order
injection, anesthesia, or surgery for my child as named. In case of emergency,
I can be reached at:
First Name: _______________________
Last Name: ________________________
Address: ___________________________
____________________________________
Home Phone: ________________________
Work Phone: ________________________
Other #: ___________________________
____________________________________
Signature of Parent or
Guardian
I also give permission for my child’s
picture to be used in brochures, web pages, etc. in promoting future events.
How much does it cost?? $55.00
_______________________________________
Signature of Parent or
Guardian
Send to Kevin
Henrickson
Questions? Contact –
Kevin Henrickson
630-337-2244
Khenric263@aol.com