VBS & Youth Programs General Registration Form

VBS & Youth Programs General Registration Form

Mountain View UMC Children
Student Information
Student Name *

First Name Middle Name Last Name
Age *
Grade Level (going into this coming school year) *
Student Birth Date *

Month Day Year
Gender *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Confidential Medical Report

The information below is requested to assist in case of any illness or accident. This information will be heldin confidence.
Please check if your child suffers from any of the following:

Heart condition Blackouts Asthma Sleepwalking Diabetes
Is your child presently taking medication? (If yes, please state the name of the medication, dosage, etc.)
Does your child have any allergies? (food/ bee sting / medication) If yes, please list.
Please list any physical or special needs: (eg. Dietary requirements)
Privacy of Information Statement
All the information recorded on this form is collected and managed with confidentiality. This information has been collected for the primary purpose of Mountain View United Methodist Church and may be used for any activities conducted or promoted by the Mountain View United Methodist Church. This information is collected solely for the safety and wellbeing of the children in our care.
Parent/Guardian(s) Information
Parent/Guardian Name - 1 *

First Name Last Name
Parent E-mail
Mobile Number *

Area Code Phone Number
Parent/Guardian Name - 2

First Name Last Name
Parent E-mail
example@example.com
Mobile Number

Area Code Phone Number
Please list the names of all persons who you authorized to collect your child/ren, while in the care of ministries of Mountain View church:
Are there any family situations we should be aware of? eg: custodial issues, other matters (please specify)
Signature of Parent/Guardian: *
Date *

Month Day Year
Date
Should be Empty:

VBS & Youth Programs General Registration Form

Student Information

Confidential Medical Report

Parent/Guardian(s) Information