Student’s name _________________________________________ Date: ____/_____/______I would like to stay in my group from last year Leader(s):___________________________________________I would like to be placed in a new group
Gender ( M / F ) Age _______ Birthday ___/_____/_____ Grade in fall semester _____School _________________________________________________________________ Address, City, zip _________________________________________________________________________________ Home phone _______________________________ Student cell # ________________________________________ Student email ____________________________________________________________________________________ Shirt size:
Three friends you want in your LUG Group: (Must be same grade and gender; please include last names.)1.____________________________ 2._______________________________ 3.______________________________
Parent(s) Info: Name: ___________________________________________________________________________________________ Cell #___________________________________________ Parent Email:____________________________________ Another emergency contact ___________________________________ phone ______________________________
Medical Insurance Co. __________________________________ Policy # __________________________________Physician ____________________________________________ Phone _____________________________________The student has the following medical condition(s):_____________________________________________________The student is on the following medication(s):________________________________________________________List any allergies the student has and the approved treatments:_______________________________________
The student understands how to care for these conditions and/or medications.
The student may take the following medicines in the age-directed dosage without further consent from me.
Tylenol ____ Advil _____Pepto-Bismol _____ Benadryl _____Vicks 44D________
Should immediate medical attention be needed for the permittee (student) due to either accident or illness, I grant a representative of Grace Fellowship Church permission to obtain such medical treatment as is required. In consideration for permission to attend Grace events, I waive any and all claims for myself, permittee and the permittee’s heirs against Grace Fellowship Church, it’s officers, directors, staff, employees, members and volunteers for any injury or illness which may directly or indirectly result for the permittee’s attendance at or participation in the above church activity. I will notify the Pastor of any custody issues that affect my child at church events. All official Church middle school events or activities will be posted on the website or communicated to your student on Sundays or Wednesday.
The student has permission to ride in Grace Fellowship vehicles and vehicles of volunteers and interns.
The student has permission to ride in the vehicle of his/her LUG-group leader.
The student has permission to meet with his/her LUG leader and LUG-group members for activities scheduled away from the
Relationship to permittee:____________________________________________ Date:__________________
Signed:_________________________________________________________________________________
Basic botanical data Official Latin Name:Pinus strobus Common Name: Pinus maritima, P. pinaster, white pine, French Marine Pine Bark Extract, French Maritime Pine Bark Extract, Leucoanthocyanidins, OPC, Oligomeric Proanthocyanidins, PCO, Pinus maritima, Pinus pinaster, Procyandiol Oligomers, Procyanodolic Oligomers, Part Used: Bark Chemistry:95% Pinus Maritima Pinus Maritima is a water-soluble fl