6/17 Where Are We Wednesdays - Governor Dick and Colebrook Crossing

Offsite Transportation Form

As a parent/ guardian, I give permission for my child to participate in the programs and activities of Cornerstone youth Center.

In addition, I give permission for Cornerstone staff to transport my child by Cornerstone van:

To: Governor Dick and Colebrook Crossing

202 Gettysburg Ave, Mt Gretna, PA 17064

On: Wednesday June 17th, from 2-6pm.

For this Where Are We Wednesday trip, we will meet at Cornerstone at 2:00pm and drive students by Cornerstone Van to get outdoors for a hike at Governor Dick. Afterwards, we will go to the Colebrook Crossing to enjoy some ice cream! Students are responsible for providing $5-10 for their ice cream. We will return to Cornerstone by 6:00pm.

If you have any questions of concerns, please contact:

Jonathan Weatherholtz at 717-723-1580 or jonathan@cornerstoneetown.org

I am aware of the inherent risks associated with these activities and that all risks cannot be prevented. If my child should require emergency medical treatment, I consent to such treatment. I acknowledge that Cornerstone does not provide accident or health insurance for youth participants, and I agree to be responsible for any medical bills incurred as a result of emergency medical treatment.

To the maximum extent permitted by law, I hereby hold harmless and release Cornerstone, its employees and volunteers, from any claims for damages or injury to my child or property, which may arise from my child’s participation in the above program and all related activities.

Name of Youth

Name of Parent/Guardian

Address

Phone

Parent/Guardian Signature

Date

Emergency Contact

Emergecy contact phone number

Description

Wednesday, June 17th , 2025

Please fill out this form and click submit.

Drinks and snacks will be provided. Students shoud bring money for ice cream!

6/17 Where Are We Wednesdays - Governor Dick and Colebrook Crossing

Description

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