tl camp permission form

							                     MINOR PERMISSION SLIP &
       EMERGENCY TREATMENT AUTHORIZATION/MEDICAL RELEASE

                                     TeenLIVE Events

EVENT:                       TeenLIVE In The Wild Camp
EVENT DATE(S):               3-5 August 2011
EVENT LOCATION:              Sherando Lake, Glenwood & Pedlar Ranger District
                             96 Sherando Lake Road
                             Lyndhurst, VA 22952
                             (540) 291-2188
RESPONSIBLE PARTIES:         Leslie Guttenberg



Meeting Location & Date/Time:       TeenLIVE, 8am on August 3rd
Return Location & Date/Time:        TeenLIVE, 4pm on August 5th

Transportation Being Used:           Private Vehicles
Costs for event: $50 per person at time of registration

Special Instructions:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Participant Information:
Name: ________________________________________________________________________
Address:______________________________________________________________________
______________________________________________________________________________

Age: ___________

Parent(s) or Legal Guardian(s):
Parent/Guardian: ____________________________________________________________________
Address: ____________________________________________________________________________
_____________________________________________________________________________________



Work Phone: _________________________________________________________________________
Home Phone: ________________________________________________________________________
Cell Phone: __________________________________________________________________________

Parent/Guardian: _____________________________________________________________________
Address: ____________________________________________________________________________
_____________________________________________________________________________________
Work Phone: _________________________________________________________________________
Home Phone: ________________________________________________________________________
Cell Phone: __________________________________________________________________________
Email: __________________________________________________________________________




MEDICAL INSURANCE INFORMATION

Medical Insurance Company__________________________________________________________
Policy#______________________________________________________________________________
Phone Number: _____________________________________________________________________


HEALTH RECORD

Is your child restricted by certain activities? _________ Explain ____________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Check if your child has had any of the following:
____ Heart trouble _____ Diabetes _____ Asthma _____ Allergies____ Epilepsy/Seizures

Other: ______________________________________________________________________________

My child is allergic to the following medications, bee stings, foods, or has other
allergic reactions: _____________________________________________________________________
_____________________________________________________________________________________

My child takes medication on a daily basis (please explain and give the name and type):
_____________________________________________________________________________________
_____________________________________________________________________________________

Please provide any special instructions or information for the group leaders: ________________
_____________________________________________________________________________________
_____________________________________________________________________________________

PERMISSION & RELEASE

In consideration for inclusion in the above event Teen LIVE In The Wild Camp at Sherando
Lake, Glenwood & Pedlar Ranger District, in Lynwood, Virginia the authority of the individual
identified as the responsible party, I hereby release, quit claim, forever discharge and agree to
hold harmless Living Faith Church, and its directors, employees, agents, assignees,
representatives and their successors in interest from any and all liability, claims or demands for
personal injury, sickness, or death my child may incur as a result of his/her participation in this
event.

In addition, I release, quit claim, forever discharge and agree to hold harmless Living Faith
Church, and its directors, employees, agents, assignees, representatives and their successors in
interest from any property damage claims I may have resulting from my child’s participation in
this event. The undersigned further agrees to hold harmless and indemnify Living Faith Church
directors, employees, agents, assignees, representatives and their successors in interest for any
liability sustained as a result of any and all acts of his/her child.

The undersigned further consents to the administration of first-aid and/or doctor’s care, or any
other form of medical treatment necessitated by illness or injury that may require the same. In
the event of the necessity of such care or treatment, I agree to hold harmless Living Faith
Church, and its directors, employees, agents, assignees, representatives, and their successors in
interest from any acts of malfeasance, and/or failure to act on the part of those chosen to
administer medical care on behalf of the participant.

In all respects, this release shall apply to the individuals named as the “responsible party” in
addition to the other entities or individuals named and held harmless by this document.



Mother/Guardian____________________________________________________________________
(signature)

Father/Guardian_____________________________________________________________________
(signature)

Date: _____________________________, 2011
                                   TeenLIVE in the Wild Camp
                                         August 3, 4, 5,
                                         $50 per person

Sherando Lake
Glenwood & Pedlar Ranger District
96 Sherando Lake Road
Lyndhurst, VA 22952

The cost is $50 per person which includes food, t-shirt, bandana, admittance to the park, personal
water bottle, and camping supplies. Please make payments to LFC as soon as possible.

Please meet in the Mountain Sanctuary (youth room) at the back of the church on Wednesday,
August 3rd, 2011 no later than 8:30am. You will need to be completely packed and ready for a
car ride of approximately two hours. Please eat breakfast before you come. You may bring
something to eat on the ride there. Lunch will be served after you arrive at camp around 1:00pm.

We will be getting back into Manassas by 3:00pm on Friday, August 5th, 2011.

Pack as lightly as possible, but make sure you have the essentials! Here’s what you need:
      Bible
      Notebook with pen/pencil
      Clothing for 3 days (remember we are in the wild and you will get dirty)
      Bathing suit
      Towel
      Tennis shoes/hiking shoes
      Bug spray
      Sunscreen
      Sleeping bag/pillow
      Flashlight
      Pajamas
      Sweatshirt
      Deodorant
      Toothbrush/toothpaste
      Personal Snacks
      Sandals/Flip flops
Optional
      Poncho
      Baby wipes
   Girls! If you have any questions about items to bring contact Christin or Kennedy.

PARENTS! If you have any questions please contact Leslie at (703)895-7939.

PLEASE NOTE: Cell Phone Coverage is limited at Lake Sherando.
                            TeenLIVE in the Wild Camp 2011
                                       Schedule

This is a basic outline of what we will be doing at camp. Activities and time schedules are not
absolute, they are just to guide the flow of each day.

Wednesday, August 3

8:30am         Arrive at TeenLIVE
9:00am         Depart for Camp
11:00pm        Arrive at Sherando Lake
1:30pm         Welcome and Greeting
2:00pm         Swimming at Sherando Lake
5:00pm                Games/Activities
6:00pm                Dinner is Served
7:00pm         Small Group Bible Study
7:30pm         Evening Worship/Teaching
11:00pm        Camp Fire/Late Night Snack
12:00am        Lights Out

Thursday, August 4

8:00am         Breakfast is Served
9:00pm                Morning Worship/Teaching
10:00am        Team Building Activities
11:00am        Hike (Hikers – Lunch in hand)
12:00pm        Lunch is Served
1:00pm                Swimming at Sherando Lake
4:30pm         Games/Activities
6:00pm         Dinner is Served
7:00pm         Small Group Bible Study
7:30pm         Evening Worship/Teaching
11:00pm        Camp Fire/Late Night Snack
12:00am        Lights Out

Friday, August 5

7:30am         Breakfast is Served
8:30pm                Clean and Pack Up
9:00am         Morning Worship/Teaching
11:00am        Go Home
3:00pm         Arrive at Living Faith, TeenLIVE Parking Lot
Questions or Comments please
contact Leslie Guttenberg at:
leslie.guttenberg@lfmi.org or
(703) 895-7939.