Name of the Child
First Name
Last Name
Age
Gender
Male
Female
Grade Level
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Church affiliation
Church Staff/Personnel
Is he/she carrying an Epi-pen at all times?
Yes
No
Does your child have any allergies?
Yes
No
What are the allergies of your child?
Does your child have any medical condition that we should be aware of?
Yes
No
What is this medical condition? Please elaborate below:
Pick Up Authorization
Authorized person/s to pickup your child after the Vacation Bible Study
Full Name 1
First Name
Last Name
Relationship
Full Name 2
First Name
Last Name
Relationship
Emergency Contact Information
Emergency Contact 1
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reminders
I allow my child to participate in this program.
I hereby authorize the Church, bible study teacher, volunteer personnel to conduct first aid, and medical care in the event of an emergency situation. I agreed to pay for all the medical care expenses and costs in a given situation that medical care is needed.
I release the organizers from any liabilities that might happen during the activity and hold them harmless in the event of damages, injuries, or accidents.
I confirm that all information in this form is accurate and true to the best of my knowledge.
Would it be okay if we take photos and videos of the participant during the activity which will be posted in our social media account?
Yes
No
Date
-
Month
-
Day
Year
Date
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: