Vacation Bible School Waiver Release Form

2016 Vacation Bible School Waiver Release Form
Wednesday, June 22 through Friday, June 24
7-9pm
Child’s Name
Age
Birthdate
Parent(s)/Guardian Name(s)_____________________________________________________________
Address ______________________________________________________________________________
Home Phone ___________________Cell Phone __________________Work Phone ________________
Parent e-mail address ___________________________________________________________________
The undersigned does hereby give permission for the above listed children to attend and participate
Family Day Ministries Vacation Bible School during the period of JUNE 22-24,2016.
Parent/GuardianSignature________________________________________Date__________
LIABILITY RELEASE: In consideration of Family Day Ministries, allowing the above child(ren) to participate
in Vacation Bible School activities, we (I), the undersigned, do hereby release, forever discharge and agree to
hold harmless Family Day Ministries, its directors, employees, volunteers and agents (collectively herein the
“Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well
as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and
the above child(ren) while involved in Vacation Bible School.
Furthermore, we (I) [and on behalf of our (my) minor child(s)] hereby assume all risk of accidental personal
injury, sickness, death, damage and expense as a result of participation in activities involved therein.
MEDICAL TREATMENT PERMISSION: We (I) authorize an adult, in whose care the minor has been
entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or
treatment and hospital care, to be rendered to the minor under the general or special supervision and on the
advice of any physician or dentist licensed on the medical staff of a licensed hospital or emergency care
facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with
such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.
Parent/GuardianSignature________________________________________Date__________
Medical Insurance: YES _____NO ____
InsuranceCompany:_______________________________________Policy/GroupID#_______________
Allergies or Medical Conditions: (If more than one child list each separately)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Activity restrictions: __________________________________________________________________
Emergency Contact person & phone #s in case parent/guardian cannot be reached:
Name: _______________________________________________________________________________
Phone #s: ____________________________________________________________________________
Parent/GuardianSignature________________________________________Date__________
Media Release
I, ________________________________________, hereby give permission for the staff and volunteers of
Family Day Ministries to photograph, videotape and/or voicetape my child/children during VBS activities for
purposes of in-house church use.
Parent/Guardian Signature: _______________________________________Date ___________
Note: All information will remain confidential to VBS Staff.
Family Day Ministries
Teresa Hall, Children’s Director
[email protected]