Winter Camp 2019 – Permission Slip

  • Time: Friday, March 8th at 6:00 PM – Sunday, March 10th at NOON
    Drop off and Pick Up at The Factory Youth Center
    Place: Refreshing Mountain Retreat and Adventure Center
    455 Camp Rd, Stevens, PA 17579

  • I give permission for my child to attend the Factory Youth Center’s Winter Camp event listed above.

    Medical Release to Grant Consent I hereby request and authorize the Factory Ministries Youth Center staff and volunteers, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information on file for my child and to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision, and upon the advice of or to be rendered by, a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child.

    Release of Activity Liability Statement I hereby release The Factory Ministries Youth Center from the responsibility of any liability involving injury or accident to my child participating in the activity listed above on the given date listed. I, as the parent or guardian of the participant listed above, will accept full responsibility for my child’s actions.

  • MM slash DD slash YYYY
  • Health Care Information

  • Is there medical or hospitalization insurance which provides benefits for your student(s)?

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