2022 VBS Medical Release Form

2022 VBS Medical Release Form

Chinese Christian Family Church, Inland Valley
Student Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Parent/Legal Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact (If parent/legal guardian is not available)*

First NameLast Name
Emergency Phone Number*
Please enter a valid phone number.
Health Insurance Company
Policy or ID Number
Family Physician
Phone Number
Please enter a valid phone number.
Family Dentist
Phone Number
Please enter a valid phone number.
Medications Currently Taking (list all, even vitamins)
List Allergies
Special Instructions Regarding Student
Date of Last Tetanus Shot*

MonthDayYear
Date
My child: Student's Name Here* may participate in all Chinese Christian Family Church, Inland Valley (CCFCIV) Vacation Bible School 2022, Make Waves events. As a parent or guardian, I authorize adult volunteers of Chinese Christian Family Church, Inland Valley as agent(s) for the undersigned, to consent to any medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clinic or hospital.

I also agree that I will immediately notify Chinese Christian Family Church, Inland Valley, in writing, of any changes to the information above, medical or otherwise. I hereby release Chinese Christian Family Church, Inland Valley, any of it's ministry leaders, and its sponsors of any legal responsibilities and liability in the event of an accident or injury en route, during and returning from Chinese Christian Family Church, Inland Valley (CCFCIV) Vacation Bible School 2022, Make Waves events.

As a parent or guardian, I have carefully and truthfully provided all the information requested and give my permission for my child to participate in Chinese Christian Family Church, Inland Valley (CCFCIV) Vacation Bible School 2022, Make Waves events. Both my child and I understand that he/she will be expected to obey the rules, regulations and policies of Chinese Christian Family Church, Inland Valley (CCFCIV) Vacation Bible School 2022, Make Waves events events.
Parent/Guardian Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty: