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Name______________________________________ Age ____ Grade ____ Gender ____
Address ___________________________________ City _____________ Zip _______
Parent’s Names ____________________________________ Phone # ______________
Parent’s Address _____________________________ City _____________ Zip _______
Alternate Contact __________________ Phone # ____________ Work # ____________
We are teaming up with
Believer’s Fellowship, Chapel
Hill and Lighthouse Christian MEDICAL INFORMATION:
School to do a World Vision 30 Allergies: _______________________________________________________________
Hour Famine Event! We’ll meet Medication Being Taken: ___________________________________________________
Friday April 30th at Light-
Physical Handicaps or Limitations: _________________________________________
house Christian School and
again on Saturday for service Medical Insurance Company: _______________________________________________
projects! More info as well as
Policy Number: ______________________ Member’s Name: _____________________
“do’s and don’ts” about fasting
will be posted online : Primary Physician: ______________________ Physician’s Phone # ________________
( and handed out
next week! Please remember to sign the release on the back of this release form!
I give permission for ________________________________ to attend “30hr Famine” with Harbor Covenant
Church (Gig Harbor, WA) April. 30th and travel to work projects on May 1st.

I hereby release Harbor Covenant Church, its staff and sponsors, from responsibility and liability for any in-
jury and illness that my child may sustain during this activity. In the event of an emergency, I hereby author-
ize an adult leader of this activity, as an agent for me, to consent to any x-ray examination; medical, dental
or surgical diagnosis; treatment; and hospital care as advised by a physician, surgeon or dentist (as appro-
priate) as listened to practice under the laws of the state/province where the services are rendered, either
at the doctors office or in any hospital. I expect to be contacted as soon as possible.

I also understand that if my child is disruptive, brings alcohol, drugs, weapons, causes any injury to them-
selves or others, or engages in any unacceptable behavior, I will be responsible to remove my child from this
activity and transport them immediately back to Gig Harbor.

___________________________________________________ __________________
Parent or Legal Guardian Date

Harbor Covenant Church, 5601 Gustafson Dr. NW, Gig Harbor, WA 98335, 253.851.8450
For more info please contact: Jen Easton,
Director of Middle School Ministries at Harbor Covenant Church
Office: 851-8450 or