Reality Student Ministries
What: School’s Out Party
What: School’s Out Party
Where: Chuck and Kippy Wolff’s House
Cost: Free
Transportation: Church Vans
When: June 17th from 6-8:30 pm
Personal Information
Name:_______________________________ Age:_____ Sex: M F (circle one)
Address:_________________________________City:__________________________
State:_____ Zip:_________________ Phone:__________________________________
Date of Birth:________________
Parent’s Information
Name:_______________________________Phone:_____________________________
Address:__________________________________ City:_____________ Zip:________
Health Information
Are you in excellent health?________ If no, why?_______________________________
_______________________________________________________________________
Do you take any medication?________ If yes, please list:_________________________
_______________________________________________________________________
I, _________________________, give permission for ____________________ to attend
the School’s Out Party on June 17, 2009 with Reality Student Ministries, of Lake Stevens
Assembly of God. I also give permission for any medical attention in case of accident,
with the understanding that reasonable effort will be made to contact me immediately. I
release Lake Stevens Assembly of God/Reality Student Ministries and agree to hold it
harmless from any liability incurred from the above named minor in connection with the
above described activity.
___________________________ _________ ________________ _________________
parent/guardian signature date cell phone emergency phone
Questions? Contact Pastor Jeff at: Phone: 425.334.3700 E-mail:
Jeffandtiffgraham@yahoo.com or go online to www.realityyouthonline.com
Reality Student Ministries
Where: Chuck and Kippy Wolff’s House
Cost: Free
Transportation: Church Vans
When: June 17th from 6-8:30 pm
Personal Information
Name:_______________________________ Age:_____ Sex: M F (circle one)
Address:_________________________________City:__________________________
State:_____ Zip:_________________ Phone:__________________________________
Date of Birth:________________
Parent’s Information
Name:_______________________________Phone:_____________________________
Address:__________________________________ City:_____________ Zip:________
Health Information
Are you in excellent health?________ If no, why?_______________________________
_______________________________________________________________________
Do you take any medication?________ If yes, please list:_________________________
_______________________________________________________________________
I, _________________________, give permission for ____________________ to attend
the School’s Out Party on June 17, 2009 with Reality Student Ministries, of Lake Stevens
Assembly of God. I also give permission for any medical attention in case of accident,
with the understanding that reasonable effort will be made to contact me immediately. I
release Lake Stevens Assembly of God/Reality Student Ministries and agree to hold it
harmless from any liability incurred from the above named minor in connection with the
above described activity.
___________________________ _________ ________________ _________________
parent/guardian signature date cell phone emergency phone
Questions? Contact Pastor Jeff at: Phone: 425.334.3700 E-mail:
Jeffandtiffgraham@yahoo.com or go online to www.realityyouthonline.com