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         Western Hills Christian Church Youth Group

Pursue Christian Teen Conference (PCTC) -  February 27-March 1, 2015

                                                        Permission Slip:

Name of Student _____________________________________ Date of Birth ____________________

Name of parent / legal guardian _________________________________________________________

Address ___________________________________________________________________________

Home phone ___________________  Work ____________________  Cell _____________________

Emergency name and number __________________________________________________________

Medical Information

Insurance Co. & Policy # ______________________________________________________________

Allergies, Medications ________________________________________________________________

I hereby give permission for the above named youth to participate in PCTC, February 27-March 1, 2015.

I hereby release Western Hills Christian Church, its staff, and youth sponsors from responsibility and liability for any injury or illness that the above named young person may sustain during PCTC, February 27-March 1, 2015.

Additionally, I authorize an adult youth sponsor of Western Hills Christian Church to act as an agent for me to consent to any X-ray, examination, medical/dental/surgical diagnosis, treatment/hospital care advised and supervised by a physician/surgeon/dentist licensed to practice under the laws of the state in which services are rendered, either at a doctor’s office or at a hospital, in the event that I am not able to make those decisions for myself.

__________________________________________                _____________________________

Signature of parent / legal guardian                                                    Date of signature



Western Hills Christian Church
908-850-8081
Located at:
40 Kennedy Road
Andover, NJ 07821

Mailing address:
PO Box 187
​Tranquility, NJ 07879
  Western Hills Christian Church
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