Rainforest Falls at Ascension VBS Permission Slip
Complete this permission slip with the child’s information, emergency contacts, insurance and physician details, medical history, allergies, family medical history, photography release, and required signatures.
Child Information
Child's Name
*
Child Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent's Email Address
example@example.com
Child Gender
Please Select
Male
Female
Child Address
Emergency Contacts
Emergency Contact 1 - Name
*
Emergency Contact 1 - Relationship to Child
*
Emergency Contact 1 - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2 - Name
*
Emergency Contact 2 - Relationship to Child
*
Emergency Contact 2 - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who to Call First in Case of Emergency - Name
*
Who to Call First in Case of Emergency - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who to Call Second in Case of Emergency - Name
*
Who to Call Second in Case of Emergency - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance & Physician Information
Insurance Provider
*
Insurance Policy Number
*
Insurance Group Number
*
Child’s Primary Doctor - Name
*
Child’s Primary Doctor - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child’s Personal Medical History
Child’s Personal Medical History
Anxiety
Asthma
High blood pressure
Diabetes
Arthritis
Seizures
Heart condition
Autism
Other
Child’s Personal Medical History - Other
Medications Child is Currently Taking
Allergies
Does Your Child Have Any Allergies?
*
Please Select
Yes
No
If Yes, List Allergies
Family Medical History
Family Medical History
*
Cancer
Mental health conditions
Diabetes
Heart disease
Stroke
None
Other
Family Medical History - Other
Photography Release
Photography Use Purposes
*
Portfolio
Website
Social Media
Advertising
Print Materials
Other
Parent’s Signature (Photography Release)
*
Date (Parent’s Signature - Photography Release)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Consent & Medical History Signature
Parent Signature (Medical History Form)
*
Date (Medical History Form)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: