VBS at LCA Registration

Child's Name (First, Last)

Address

City

State

Zip code

Primary Phone Number

Format: (000) 000-0000.

Last Grade Completed

Fathers Name

Phone

Format: (000) 000-0000.

Mothers Name

Phone

Format: (000) 000-0000.

Church Attending

In Case Parents Cannot Be Reached

Name

Phone (cell)

Format: (000) 000-0000.

Authorized Release The following person(s) MAY pick up my child from VBS

Name

Please explain in detail if your child is being treated for ANY medical condition or if they have ANY dietary restrictions that we need to be made aware of

Emergency Medical Contact Information

Pediatrician

Phone

Format: (000) 000-0000.

Hospital Preference

Phone

Format: (000) 000-0000.

Insurance Information Primary Insurance Provider

Policy Number

Please list any Food Allergies request and food allergy form AND supply a action plan from your childs pediatrician or allergist

Major Illness Surgical Procedures Hospitalizations

DisabilitiesHandicaps

Please explain any physical limitations your child may have that would limit their ability to participate in activities

Medications Please list any Medications that your child is allergic to:

Please note for the safety of your child, only the parents and authorized release will be able to pick up your child from our program.

By signing below, I, the undersigned parent/guardian of the child names above, hereby give permission for my child to participate in the Vacation Bible School program hosted by Lighthouse Chrisitan Academy at Grace Baptist Church. I understand that participation in VBS may involve physical activities and group interaction, and as with any program involving children, there is a risk of injury. I acknowledge that I accept these risks. I hereby release, hold harmless, and discharge, Grace Baptist Church and Lighthouse Christian Academy, its staff, volunteers and affiliates from any and all liability, claims, or demeans for personal injury, illness or property damage that may arise from participation in this program, to the fullest extent permitted by law. In the event of an emergency, I authorize GBC or LCA, staff or volunteers to seek emergency medical treatment for my child and to act in my place in securing necessary care. I understand that I am finically responsible for any medical treatment.

Signature of ParentGuardian

Date