Form
Parent #1
*
First Name
Last Name
Parent #2
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Emergency Contact
*
First Name
Last Name
Child #1
First Name
Last Name
Food Allergies?
Child #2
First Name
Last Name
Food Allergies?
Child #3
First Name
Last Name
Food Allergies?
Child #4
First Name
Last Name
Food Allergies?
Child #5
First Name
Last Name
Food Allergies?
Child #6
First Name
Last Name
Food Allergies?
I give permission for my child(ren) (named above) to attend Radiant Fellowship’s Vacation Bible School August 5-8, 2024. I hereby authorize the leaders, volunteers, Radiant Fellowship, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision, and upon the advice of or to be rendered by, a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child.
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