FCC Youth Roller Skating

Student's Name

Student's Phone

Student's Date of Birth

Parent/Guardian's Name

Parent/Guardian's Phone

Secondary Emergency Contact and Phone Number

Health Insurance Carrier and Policy Number

Any allergies/Disabilities? (This will also help us order the correct pizza)

Please Read and Sign

I understand all reasonable safety precautions will be taken at all times by Faith Community Church and its agents during the event and activities. I authorize any treatment by an accredited hospital and/or physician deemed necessary for the subject of the release in case of an emergency. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Faith Community Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. I give permission for my son/daughter to attend.

Payment

*If you have your own skats or rollerblades we still get charged for you to skate so you still need to pay the minimum fee of $15.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

October 29, 6-8pm

Thanks for successfully completing the FCC Youth Roller Skating Permission Slip for Thursday Oct. 29, 6-8pm at the Santa Cruz Roller Palladium.

Cost is $15 for pizza and skating ($3 extra to rent rollerblades)

Don't forget to wear a halloween costume for our epic Halloween Costume Contest!!!

FCC Youth Roller Skating

Description

Please Fix the Following