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All-State Permission Slip 26

Location: Grace & Truth Bible Church, 410 Pleassant View Road, Hummelstown, PA 17036

Date: November 19-21

Departure & Return times: Leaving school, November 19th at 1 p.m.

Cost: $55 for registration fee and $80 for the housing at Holiday Inn. The cost for the trip can be paid by cash or check made payable to Canaan Christian Academy, OR by debit/credit card at the bottom of the form.

Transportation: School vans

Chaperones: The trip will be chaperoned by Mrs. Musser & Pastor Dan & Jen Henwood

Emergency Phone numbers: 570-856-0773 (Mrs. Musser) Grace & Truth Bible Church 717-566-9329

PERMISSION SLIP AND MONEY ARE DUE BY

NOVEMBER 18th.

Student First & Last Name*

Answer required for "Student First & Last Name"

Parent/Guardian First & Last Name*

Answer required for "Parent/Guardian First & Last Name"

Parent/Guardian Phone Number*

Number Required

Emergency Contact Name*

Answer required for "Emergency Contact Name"

Emergency Contact Phone Number*

Number Required

Family physician*

Answer required for "Family physician"

Family physician phone number*

Number Required

Special medical conditions:

Answer required for "Special medical conditions:"

I give my consent as the parent or guardian of the above named student to participate in this event. In doing so, I agree to the following:

In case of a medical emergency, I grant the chaperones the right to authorize medical care, if none of the persons named above can be reached.
I agree to pay the expenses of returning my child home before the end of the event if he or she does not adhere to the established standards of conduct.
The school is not responsible for damage or loss of property personally owned by my child.

Cash or check by November 18th

Answer required for "Cash or check by November 18th"

$135.00

Payment by debit or credit card

Answer required for "Payment by debit or credit card"

$135.00

Parent/Guardian Signature*

Signature Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"