1.

Name ________________________________ Phone #’s _________________________________________

Emergency Contact
Medical Insurance _________________________________Policy # ___________________________________

Medical Conditions or Medications _____________________________________________________________

Address _______________________________________City __________________ St. _____ Zip __________

Name _________________________________________Phone ________________________ Sex __________

Our special guest speaker,

Please fill out BOTH SIDES and return to the Youth Office with the $115 cost by
Don Mullis!

PLEASE SIGN BOTH SIDES OF THE FORM– Chaperones, yes, you too!
Mr. Mullis will be sharing with us
the importance of the gospel in
our lives.

What:
What to Bring:
A fantastic weekend of sledding,
A tube or sled if you have one (plastic only), bicy-
music, games, hanging with your friends,

Sunday, December 20th.

cle helmet, snow boots, warm clothes, Bible, pen,

Registration
and being challenged by God’s Word.
notebook, towel, sleeping bag, pillow, and $ for
Where: dinner on the way there.
Deer Valley YMCA Camp in Fort Hill, PA.
DON’T Bring:
We will be staying and sledding right at the
No Bad attitudes, Fireworks, Tobacco
camp.
Products, Alcohol or Drugs, Ipods or
When:
any electronic video games.
We will leave 4:30 pm Friday, January 15th,
Important dates to remember:
from the church. We will return on Sunday,
Dec 20– registration/permission slip and
January 17th at 5:00 pm.
$115 cost due
Cost: Jan 15-Leave for retreat 4:30 pm.
Jan 17– Return to church about 5:00 pm.
$115 per person (make checks payable to EP
Church). Cost covers all meals, lodging, trans-
Parents:
portation and sledding. Space is limited so sign
If you are interested in coming along, please con-
up today! Both the permission slip and payment
tact the youth office at 410-266-8091 x116.
must be turned in to be registered.
 PERMISSION SLIP

Annapolis, MD 21401
710 Ridgely Ave
Annapolis EP Church
Please fill out both sides and return to
the Youth Office with the $115 cost by
Sunday, December 20th.

I, the undersigned parent/guardian, authorize my

child,

___________________________________
Child’s name printed clearly

To attend the Winter Retreat at Deer Valley

YMCA Camp in Fort Hill, PA, with the
Evangelical Presbyterian Church of Annapolis.
In the event of an emergency and I cannot be
reached, I hereby give consent to the
necessary and proper treatment, surgery or
anesthesia by a licensed physician or health
care professional for my child. Therefore I
release EP Church of Annapolis and their
agents or employees from any and all liability
related to the activities of this weekend.

Parent’s Signature

___________________________________

Date
___________________________________
January 15th—17th, 2010
Phone Annapolis EP Middle
___________________________________
Have you signed both sides of the form? School Youth
Thanks!