Clone of VBS Registration

Emergency Contact:*

First NameLast Name
Emergency Contact Phone:*

Area CodePhone Number
Emergency Contact 2:

First NameLast Name
Emergency Contact Phone 2:

Area CodePhone Number
Special Needs / Alergies / Medications Student is taking/ Concerns we should know about:*

The undersigned gives permission to his or her student to participate in the winter retreat and In the event I cannot be reached in an EMERGENCY, I hereby give permission to volunteers of American Lutheran to seek care for my student. I also give permission for the physician selected to treat my student.

By signing this registration form you also agree that any photographs taken of your student at or during this event may be used in future publications as deemed appropriate.
Parent's Name:*

First NameLast Name
Signature*

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Date*

MonthDayYear
Date
By submitting this form, I give consent to American Lutheran Church of the child above
Insurance Company:*
Policy No.:*
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Registration Form