Vacation Bible School Registration Form

Vacation Bible School
Registration Form
2016
Child’s Name (Last)
Age
(First)
Date of Birth
Address
Grade
(as of Spring 2016)
City/St
Zip
Parent’s Name (Last)
(First)
Home Phone #
E-mail
Parent’s Cell #
Parent’s Work #
Does this child have any medical condition(s) that we should be aware of (allergies, medications, etc?)
If so please explain. _______________________________________________________________________
________________________________________________________________________________________
Dismissal & Emergency Contact Information (To serve your child in case of ACCIDENT OR SUDDEN ILLNESS)
1. Name
Phone #
2. Name
Phone #
T-shirt size: (Please circle one) CHILD
XS
SM
MED
LRG
ADULT
SM
MED
LRG
XL
XXL
Siblings who will also be attending VBS _________________________________________________________
Permission granted to photograph/video and release images. (Please circle one)
Yes
No
I would like to volunteer to help with __________________________________________________________
Church use only/Other Information
_______________________________________________________________________________________
_______________________________________________________________________________________
Medical Authorization
I, _____________________________________________, being the parent/legal guardian and
having legal custody of _______________________________________________, a minor, do
hereby consent to said child participating in activities and related trips of Seventh-day Adventist
Church of_________________________. I do hereby release, discharge and exonerate
Seventh-day Adventist Church, and all persons acting as teachers or sponsors on said
activities and trips from any liability whatsoever resulting from personal injury to said minor or
damage to property of said minor which may occur at said activities or trips or connection
therewith.
I do hereby certify that I assume full responsibility and liability for any acts committed by said
minor during activities, and trips related thereto resulting in injury or damage to the property of
another.
I do hereby acknowledge that I understand that this release is being relied upon by Seventhday Adventist Church, and teachers or sponsors accompanying the children on said trips and
activities; and without this instrument being executed by me, said minor would not be permitted
to attend field trips nor engage in activities related thereto.
I, do hereby authorize the officials of Seventh-day Adventist Church to contact directly the
person named in this authorization, and do authorize
________________________________________ or _________________________________
(Physician)
(Hospital)
to render such treatment as may be deemed necessary in an emergency, for the health of said
child. In the event physicians, other persons named in the authorization or parents cannot be
contacted, the church officials are hereby authorized to take whatever action is deemed
necessary in their judgment, for the health of the aforesaid child. I will not hold Seventh-day
Adventist Church financially responsible for the emergency care and/or transportation for said
child.
Parent/Guardian Signature: ___________________________________________________
Date: __________________