Fall Lock-Out 2009

Community Church Junior High Ministry

This is our all night Element
Kick-Off event. We’ll meet at the
church at 9pm, get to know one an-
other eat some snacks and then pack
in vans and drive to Kokomo’s in
Cost: $35
(+ change if you play video games)
Saginaw to spend the night on their
roller coaster, go-karts, video games,
laser tag, and eat pizza. At 4am, Time: 9pm Fri. Sept.18
we’ll pack in the vans and drive back
to Mount Pleasant, where we’ll go to a To
restaurant for some delicious break- 8am Sat. Sept.19
fast and then head back to the church
to wind down and get picked up. This Who: 7th & 8th graders
is the perfect event for kids who aren’t
sure whether or not the Element is for
them. They’ll get to meet all the other Sign up Deadline: Sept 14
kids in the group and have a blast.

downloads / forms / info - element.slimwired.com

I, ________________________________(parent/guardian), give permission for _________________________________(student)

to take part in the Kokomo’s Lock-Out including, but not limited to transportation and activities, on September 18, 2009. I understand the
nature of the event and do hereby release Mount Pleasant Community Church, its employees, staff and volunteers from all liability or claims
arising from or related to the event. In the event of an emergency, I hereby authorize 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 or hospital care advised and supervised by a physi-
cian, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doc-
tor’s office or in any hospital. I expect to be contacted as soon as possible.

Home Phone: _________________________ Mobile Phone (parent): _________________________

Address: ___________________________________________________________ Class of 20_____

Parent/Guardian Signature: ____________________________________________ Date: ____________

Office use only: Deposit Cash Check # Balance