LH TEENS TAKE OVER COSMIC AIR- NORTH CAMPUS

Saturday July 1, 2023 @ 7pm | LH TEENS (13yrs -18yrs) & Parents! Grab a friend and come hang out at COSMIC AIR in HUMBLE with us Saturday, July 1st from 7pm-9pm! PLEASE BE SURE TO COMPLETE THE ACTIVITY WAIVER in its entirety FOR EACH TEEN! Can't wait to see you guys there!

Today's Date

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The undersigned parent/legal guardian hereby gives permission to The Lighthouse Church, for my child(dren) to take part in this activity. One waiver per child.

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Parent/Guardian Name

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Email

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This address will receive a confirmation email

Phone

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List All LH Teens that will be attending Cosmic Air Ages 13-18! Please complete each field for each teen including the activity participation waiver.

Name of Teen 1

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Birthday

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Grade

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Please select one option.

7th 8th 9th 10th 11th 12th

Checking this box gives the child listed above permission to participate:

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Please select all that apply.

Yes, my child has permission to participate.

Name of Teen 2

Birthday

Grade

Please select one option.

7th 8th 9th 10th 11th 12th

Checking this box gives the child listed above permission to participate:

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Please select all that apply.

My child has permission to participate.

Name of Teen 3

Birthday

Grade

Please select one option.

7th 8th 9th 10th 11th 12th

Checking this box gives the child listed above permission to participate:

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Please select all that apply.

My child has permission to participate.

Name of Teen 4

Birthday

Grade

Please select one option.

7th 8th 9th 10th 11th 12th

Checking this box gives the child listed above permission to participate:

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Please select all that apply.

My child has my permission to participate.

Name of Teen 5

Birthday

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Grade

Please select one option.

7th 8th 9th 10th 11th 12th

Checking this box gives the child listed above permission to participate:

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Please select all that apply.

My child has my permission to participate.

PLEASE READ CAREFULLY, THIS PERMISSION SLIP IS A LEGAL DOCUMENT WHICH INCLUDES A RELEASE OF LIABILITY AND INDEMNIFICATION Should my child(ren) require immediate or emergency medical care while engaged in an activity sponsored by The Lighthouse Church, in my absence, I hereby grant The Lighthouse Church authority to release my child(ren) for medical treatment to such medical personnel as The Lighthouse Church determines appropriate under the circumstances. In consideration for the privilege of allowing my child(ren) to participate in the above-named activity, I agree to release and hold harmless The Lighthouse Church, its officers and agents, from any liability to or responsibility for bodily injury, damage or illness to the above-identified child(ren) while participating in any youth athletic or social activity which may be directly or indirectly sponsored by The Lighthouse Church. Further, I agree to indemnify and hold harmless the Church, its officers and agents with respect to any claim asserted by or on behalf of my child(ren) as a result of bodily injury, illness, or damage. Place your initials here to acknowledge reading of the permission slip.

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Parent/Guardian Initials

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Emergency Contact Name

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Emergency Contact Number

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Insurance Name

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Insurance Member Number

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*By Entering my name in the box below, I am providing my electronic signature and approval on the information provided and released.

Electronic Signature of Parent/Guardian

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If you have any additional questions or concerns, please send them via email to KDZ@lhhouston.church

Payment

1 Teen ($10) 2 Teen ($20) 3 Teen ($30) 4 Teen ($40) 5 Teen ($50)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

Saturday July 1, 2023 @ 7pm

LH TEENS (13yrs -18yrs) & Parents! Grab a friend and come hang out at COSMIC AIR in HUMBLE with us Saturday, July 1st from 7pm-9pm! PLEASE BE SURE TO COMPLETE THE ACTIVITY WAIVER in its entirety FOR EACH TEEN! Can't wait to see you guys there!

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