PERMISSION/MEDICAL RELEASE FORM

Activity / High School Ski Trip
Group(s) invited / High School Students
Purpose / To fellowship and build community with one another
Date(s)/Time (start/end) / Friday, January 27 to Saturday, January 28
Activity Location(s)
(If multiple give approx. time(s) at each location) / Liberty Ski Resort and the Quality Inn
Leader (phone/email) / Nathan Orlandi – (301) 787-3799
Backup* (phone/email) / Dave Hornickel – (301) 848-2508
Chaperones / Nathan Orlandi, Elisa Orlandi, Melissa Haynes, Bill Voshell, Dave Hornickel
Transportation (drivers-vehicle type) / Nathan Orlandi (Church Van), Bill Voshell/Dave Hornickel (Church Van), Elisa Orlandi (Toyota Sequoia)
Lodging (location/dates) / Quality Inn (Gettysburg) – Friday, January 27
Cost/Individual / $160 for everything ($125 without equipment rental)
Other Info (i.e. special clothing needs for activities, things to bring, etc.) / Departure time: 3:45PM on Friday, January 27
Return time: 8:00PM on Saturday, January 28
Money for three meals (two fast food and one at the ski lodge)
**More details online and in e-mail**

*Backup will have access to ALL information leader has; including contacts for all participants

I am the parent/guardian of ______Date of Birth______

(Full Name of child)

I have read the trip details above and authorize my child's participation in any activity that will take place during High School Ski Trip on January 27 and 28 with Grace Brethren Church. I also GIVE PERMISSION for my child to RIDE WITH ANY PERSON PROVIDING TRANSPORTATION WHOSE NAME IS CIRCLED ABOVE .

By signing this document I certify that I have legal custody of the child listed on this form. I also certify my child has a current health information form on file at Grace Brethren Church and that if any information on that form has changed since submitting it, I will turn in a health information form with updated information for this trip.

I give permission for the adult leaders from Grace Brethren Church Staff to seek medical treatment for my child. In the event of an emergency, I consent for my child to receive such medical treatment and/or surgical procedures deemed necessary by medical personnel. I hold harmless and fully and forever release and discharge Grace Brethren Church, all officers, agents and volunteers and or employees or staff of Grace Brethren Church from any and all claims, demands, rights of action, present or future, whether the same be known, anticipated or unanticipated, resulting from, or arising out of, or incident to, the providing of this medical assistance.

I assume liability for any medical expenses involved. The insurance coverage (if any) that we carry will be the primary coverage for my child. I understand that every reasonable effort will be given to contact me as soon as possible should an emergency arise.

This release shall be in effect during the time that the above named minor is in the care and custody of Grace Brethren Church; and shall include but not be limited to transportation to and from activities sponsored by Grace Brethren Church.

______

Father’s Signature or Guardian Date

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Mother’s Signature or Guardian Date