Christ Church Lake Forest

First Name:

Last Name:

Phone:

Student's Email:

Parent's Email:

Address:

City:

State:

Select State Illinois Wisconsin Indiana

Zipcode:

School:

Grade:

Mission preference:

Memphis, TN: June 13-19, 2010

Acuña, Mexico: June 12-20, 2010

T-Shirt Size:

S

M

L

XL

XXL

Physical Condition of Student
Please check all that apply giving details where necessary.

If you filled out the release form in the fall, check this box and leave below blank.

Allergies

Asthma

Diabetes

Stomach upsets

Heart Condition

Epilepsy/nervous disorder

Other:

1. In case of accident, illness or injury, I hereby give permission for medical attention to be given to my son or daughter.
2. I hereby release Christ Church Lake Forest from liability in case of accident.
3. I hereby request supervisors in the Youth Department to carry out any discipline deemed necessary for my child. I also agree, if necessary, to pay the cost of my child being sent home as a result of disciplinary action.

Parent's Name:

Current Medications:

Medical Insurance Company:

Policy #:

I'll pay $50 through paypal

I'll pay $50 in person