WOW Wednesdays Vacation Bible Study

WOW Wednesdays Vacation Bible Study
Institution Name
STUDENT INFORMATION
Name

First NameLast Name
M.I.
Birth Date

MonthDayYear
Date
Gender
Grade completed this past school year.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACTS
Please list the first and last names and phone numbers off ALL adults who are allowed to pick up this child. The child will only be released to these people.
Primary Guardian

First NameLast Name
Phone Number
Format: (000) 000-0000.
Alternate Guardian #2

First NameLast Name
Phone Number
Format: (000) 000-0000.
EMAIL Address:
Medical Information
Please list all allergies -- or type "none" if there are none
Does your child carry an epi-pen? (please note: if yes, it is the responsibilty of the child's guardian to ensure the child has the epi-pen at every drop off and pick up)
Please list all medical concerns -- or type "none" if there are none
Additional Information

1. I allow my child to participate in this program.

2. I hereby authorize the volunteer personnel to conduct first aid, and medical care in the event of an emergency situation.

3. I confirm that all information in this form is accurate and true to the best of my knowledge.

4. I release the organizers from any liabilities that might happen during the activity and hold them blameless in the event of damages, injuries, or accidents.
Other Information or Special Concerns for this participant.
Signature
By submitting this form, I ackowledge I have read and understand the above information.
Should be Empty:

WOW Wednesdays Vacation Bible Study

Medical Information

Additional Information