Student Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Parent/Guardian Name(s) *

First Name

Last Name

Cell Phone *

(###)

###

####

Parent/Legal Guardian Signature *

My child listed above has the permission of the name typed below to participate in the following described event: Church Camp @ Mt. Lebanon on 7/15/2024-7/19/2024 By typing my name, I understand that participation in the stated event includes transportation to and from the destination by an adult worker for the Quest Church Youth Ministry or chartered bus.

First Name

Last Name

Parent/Legal Guardian Signature Date *

MM

DD

YYYY