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ReleASe FORm next vaLley Lock in ’09 student’s name


emergency contact



Christmas is over and it’s almost a week until school starts again... who wouldn’t want to spend an entire night locked up in a church, playing games, winning prizes, eating food, watching movies, and getting to know the other students at Next Valley?

WHO & WHEN Monday, December 28 | 9 pm – 7 am is just for Girls Tuesday, December 29 | 9 pm – 7 am is for Guys only

WHERE Pleasant Valley Church | 330.539.6582 2055 Pleasant Valley Rd | Niles, OH 44446

WHAT Bring comfortable clothes and a sleeping bag & pillow (if you dare to attempt sleeping). Basically we’ll stay up all night, play games, eat pizza and watch movies, all under the supervision of Next Valley’s adult staff. This is a lot more exciting than it sounds on paper, so bring a friend. We’ll be drawing names throughout the night to win free prizes. When you come, you’ll get 1 ticket if you come alone, 5 tickets if you bring a friend, and 10 tickets if you are that friend, who doesn’t regularly attend Next Valley! More tickets means more chances to win.

ConTact infO

If you have questions or need to contact someone the night of the lock-in For Girls: Call Stephanie Garasic @ 330.503.5149 For Guys: Call Thad Gwin @ 330.469.1405 Or call the church/Doug Garasic at 330.539.6582 ext.104

For the above named participant, I consent to his/her participation in the Next Valley Youth Lock-In on December 28, 2009 (if the participant is female) or December 29, 2009 (if the participant is male). I acknowledge that he/she assumes the risk of injury. I realize that Pleasant Valley Evangelical Church intends to take reasonable precautions against accidents; nevertheless, I agree to release and hold harmless Pleasant Valley Evangelical Church, its staff, agents, volunteers and officers, with respect to injuries, claims, damages or demands which may arise out of any accidents which might occur during this outing. This release includes damage or destruction of the participant’s clothing and personal belongings. Further, I agree that the participant shall make restitution for any damages resulting from his/her negligent conduct. I also give Pleasant Valley Evangelical Church and any health care providers receiving referrals to render emergency medical care and treatment to the above named participant in connection with any illness or injury which he/ she may encounter while participating.

health insurance/medicaid no.

signature of parent/guardian


Lock in Permision Form  

the permission form for the girls/guys lock in

Lock in Permision Form  

the permission form for the girls/guys lock in