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W I N T E R C A M P   2 0 0 1

(print this and have your parent or guardian sign it!)

Name of Participant (youth): ________________________________________

Parent/Guardian’s name: ___________________________________________

In signing this form, I hereby give permission for my son/daughter to participate in Hopewell Presbyterian Church's Senior High Fellowship's “WINTERCAMP" trip to be held from Friday, February 2, 2001 through Sunday February 4, 2001.   I also grant permission for my son/daughter to be transported in privately owned or rented vehicles.  Further, I will not hold the church staff nor youth leaders, nor any of its representatives or Trustees responsible for any injuries sustained during the course of activities for the above dates and times.

In case of a medical emergency, I understand that every effort will be made to contact the parent/guardian of the young person.   In the event that I cannot be reached, I hereby give permission to the physician selected by the staff or person designated by the staff to give medical attention to my child, as named herein.

Family Health Insurance Company: ____________________________________

Policy Number: ___________________________________________________

Telephone #’s where I can be reached: _________________________________

Signature of Parent/Guardian: _______________________________________

Any medical or other health-related problems we should be aware of:

Note: We must have a permission slip for each person attending this event.  If you do not have your permission slip, you will not be permitted to attend.  Sorry, but we have to be sure you have permission and the needed medical data in case of an emergency.  Thanks!

Another Note:  Unless you are a leader, you must have this signed by a parent.

Questions?   Call Elizabeth Barrows at 609-937-6153 or Norm Hurst at 609-466-9465.