CBC VBS 2022

Child Information

Child Name

First Name Last Name

Birth Date

Month Day Year

Current Grade:

Gender

Male Female

Parent/Guardian Information

Name

First Name Last Name

Home Number

Cell Number

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First Name Last Name

Relationship

Phone Number

Alt. Phone Number

Any allergies, chronic illness, or medical conditions? If yes, please describe.

Medical Release and Authorization

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Community Bible Church and its affiliates including Directors and Volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the Vacation Bible School.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Informed Consent and Acknowledgement and Media Release.

I hereby give my approval for my child’s participation in any and all activities prepared by Community Bible Church during Vacation Bible School. In exchange for the acceptance of said child’s candidacy by Community Bible Church, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Community Bible Church and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected VBS sessions.

In case of injury to said child, I hereby waive all claims against Community Bible Church including all volunteers and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

I give Community Bible Church Children’s Ministry and its agents my permission to use pictures of me or my child(ren) in videos and digital still images and to reproduce their name on audiotapes, recordings, reproductions, websites, i.e. documents, DVDs, movies and any or all photographs.
I hereby release Community Bible Church, its employees and agents from any and all claims for damages, libel, slander, invasion of the right of privacy, or any other claim based on the use of photographs or videos.
No promises have been made to me in exchange for my signature on this release. I have read this release form and fully understand the meaning of it. I am of legal age and have every right to sign this form.

Child T-Shirt Size:

Small Medium Large Adult Small Adult Medium Adult Large

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Clear

COMMUNITY BIBLE CHURCH VBS REGISTRATION