ACQUIRE THE FIRE 2014 – May 2nd-3rd

Activity Permission Form
ACQUIRE THE FIRE 2014 – May 2nd-3rd
Permission must be granted by parent or guardian for children under the age of 18 to travel to or from church property
for services, or outside activities. The information on this form must be completed, signed and dated for permission to
be considered granted. Medical info. must be completed for all participants.
Youth’s full name ______________________________________
Address ____________________________________________________________
City _____________________________ State ___________ Zip ___________
Phone (
) ______________ Emergency Contact: (____) _________________
Parent or legal guardian, please sign below:
I hereby grant permission for my son/daughter to attend the 2014 Acquire the Fire trip sponsored by Word of Grace
Christian Center, 13832 Redskin Dr., Herndon, VA. This includes permission to transport my son/daughter to and from
Acquire the Fire, Baltimore MD, including the event arena, hotel and restaurants. I understand that this activity will be
chaperoned by an adult sponsor of Word of Grace Christian Center.
RELEASE OF LIABILITY
In consideration of being allowed to attend this trip with Word of Grace Christian Center, I HEREBY AGREE NOT TO SUE
AND TO RELEASE, WORD OF GRACE CHRISTIAN CENTER, ITS TRUSTEES, AGENTS AND/OR EMPLOYEES, FROM ANY AND
ALL LIABILITY RELATED TO INJURY, PROPERTY LOSS OR OTHERWISE RELATED TO THIS ACTIVITY, REGARDLESS OF ANY
NEGLIGENCE ON THE PART OF WORD OF GRACE CHRISTIAN CENTER. I FURTHER AGREE TO INDEMNIFY AND DEFEND
THE SAME, FROM ANY CLAIM FOR LIABILITY RELATED TO INJURY AS A RESULT OF MY OR MY CHILD’S PARTICIPATION
AND USE OF ANY FACILITIES, REGARDLESS OF ANY NEGLIGENCE.
____________________________________________________
Signature of parent or legal guardian
Trip Info.
Event:
____________________
(Date)
Acquire the Fire
Duration of event: 1:00pm Friday, May 2nd to Saturday May 3rd @11:00pm
Description: An awesome Christian youth event designed to empower teens to turn from the world, live for
Jesus Christ every day, and share what He has done for them with others. See http://www.acquirethefire.com
for more details.
Event Location: Baltimore, MD, First Mariner Arena, 201 West Baltimore Street, Baltimore, MD 21201, USA
Hotel where we’ll be staying:
A very nice hotel (with a pool) directly behind the event center.
Days Inn Inner Harbor, 100 Hopkins Place, Baltimore, MD 21201 Tel: (410) 576-1000
Youth Leaders: Jeff Kinnick (cell 703.728.7790), Lidiane Kinnick, Kris Dion (cell 703.930.4830), Anita
Kaarsburg
Cost: $69 (includes Event Admission, Hotel, and Transportation)
Additional money to bring: $30 for dinner Friday, lunch/dinner on Sat (You could pack a dinner for Friday)
Items the youth need to bring: Bible, pen, toothbrush, toothpaste, etc.
Please fill out the health history and Emergency Medical Information on the next page completely. These forms
will be kept on file for your youth for future events.
Health History and Emergency Medical Information
Please fill out this form completely. This form will be kept on file for your youth for future events. Please let us
know of changes.
Youth Name ____________________________________Date: _____________
Health History:
Has he/she had:
Yes
Attack of Appendicitis ____
Asthma or hay fever ____
Hernia (rupture)
____
Rheumatic Fever
____
Diabetes
____
Does he/she take insulin ____
Poliomyetis
____
Heart Trouble
____
Severe Allergies
____
Scarlet fever
____
Significant disease, injury,
or operation
____
Is he/she under medical care
requiring medication? ____
No
____
____
____
____
____
____
____
____
____
____
____
____
Is he/she subject to:
Yes
Sinus trouble
Fainting spells
Ear trouble
Convulsions
Poison Ivy, oak or sumac
Reaction to penicillin
Nervousness or easily upset
Allergy to aspirin
____
____
____
____
____
____
____
____
No
____
____
____
____
____
____
____
____
Date of last Tetanus shot ___/ ___/______
Is he/she restricted
due to medical reasons?
____
____
If answer is ‘Yes’ to any of the above please explain in the space below.
Emergency Medical Information:
Home Phone: (____) _____________ Father’s Cell: (____)_____________
Mother’s Cell:(____)______________Emergency Contact #: (____)____________
Insurance Company _________________ Ins. Co. Phone: (____)_____________
Address _________________________________________________
_________________________________________________
Insurance Card # ___________________ Policy # ________________________
Family Doctor _____________________ Phone (_____)___________________
Tentative Schedule
Duration of event: 1:00pm Friday, May 2nd to
Saturday May 3rd @11:00pm
Description: An awesome Christian youth
event designed to empower teens to turn from
the world, live for Jesus Christ every day, and
share what He has done for them with others.
See http://www.acquirethefire.com for more
details.
Event Location: Baltimore, MD, First Mariner
Arena, 201 West Baltimore Street, Baltimore,
MD 21201, USA
Hotel :where we’ll be staying: A very nice hotel
(with a pool) directly behind the event center.
Days Inn Inner Harbor, 100 Hopkins
Place, Baltimore, MD 21201 Tel: (410)
576-1000
Youth Leaders: Jeff Kinnick (cell 703.728.7790),
Lidiane Kinnick, Kris Dion (cell 703.930.4830),
Anita Kaarsburg