VBS Registration Form - Calvary Chapel Beachside

VBS Registration Form
July 18-22, 2016
Monday – Friday, 9 am–12 noon
For those going into Kindergarten through 6th Grade
Cost: $25 per child – Space Is Limited
Please fill in completely,
make checks payable to, and return to
Calvary Chapel Beachside
19400 Beach Blvd
Huntington Beach 92648
(714) 465-3000
Father’s Name
Father’s Cell (
)
Mother’s Name
Mother’s Cell (
)
E-mail address
Address, City, Zip
1. Child’s Name
Age
T-shirt size: Child’s S M L XL Adult’s S M
2. Child’s Name
3. Child’s Name
4. Child’s Name
Office Use Only: Amount:$
cash
Grade Entering
Birthdate
Grade Entering
Food Allergies/Medical Concerns
Age
T-shirt size: Child’s S M L XL Adult’s S M
Birthdate
Food Allergies/Medical Concerns
Age
T-shirt size: Child’s S M L XL Adult’s S M
Grade Entering
Food Allergies/Medical Concerns
Age
T-shirt size: Child’s S M L XL Adult’s S M
Birthdate
Birthdate
Grade Entering
Food Allergies/Medical Concerns
Check #
Date
www.calvarybeachside.com
Initials:
Emergency Medical Release
Vacation Bible School, July 18-22, 2016
CALVARY CHAPEL BEACHSIDE
19400 Beach Blvd #26
Huntington Beach, CA 92648
714-465-3000
Please be advised that the bearer of this form has full and complete authority to approve any emergency medical or
dental care deemed necessary for my son(s) or daughter(s),
Minor Children’s Name(s)
I hereby grant permission for my child to attend and participate in the Vacation Bible School at Calvary Chapel
Beachside of Huntington Beach the week of July 18-22, 2016. This authorization includes x-ray examination,
anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care. Such diagnosis or treatment is to be
rendered under the general supervision of any dentist, physician, or surgeon licensed under the provisions of the
Medical Practice Act, whether at the office of said dentist or physician or at a hospital. It is understood that a
conscientious effort will be made to notify me before such action is taken. This authorization is given pursuant to
Section 25.8 of the Civil Code of California. This authorization shall remain effective through the extent of the VBS
week (July 18-22, 2016) with Calvary Chapel Beachside unless sooner revoked in writing. I further agree that Calvary
Chapel Beachside, its Board of Directors, officers, staff, and volunteers are hereby relieved of all liability in the event of
accident or injury to said Minor(s).
I do further authorize said agent to select transportation to chosen dentist, physician, or hospital. This authorization will
remain in effect while said minor is en route to or from involved or participating in any program or activity authorized by
CALVARY CHAPEL BEACHSIDE unless revoked by the undersigned in writing and delivered to the aforesaid agent. I
hereby authorize any hospital which has provided treatment to the above named minor(s) to surrender physical
custody of such person to said agent upon completion of treatment. This authorization is given pursuant to the
provisions of Section 25 of the Civil Code of California, and to Section 1283 of the Health and Safety Code of
California.
Print name of Parent/Guardian
Number to be reached in case of emergency
__________________
Signature of Parent/Guardian
Name of Insurance Co.
Date
Policy #
Policy Holder