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VBS
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VBS Registration
Enter your Child's Information Below:
Child's Name*:
Child's DOB*:
Child's Gender:
M
F
Grade (Completed)*:
N/A
K
1
2
3
4
5
6
7
8
9
10
Parents/Guardians*:
Email Address*:
Street Address*:
Home Phone*:
Additional Phone Numbers:
Emergency Contact*:
Emergency Contact Address:
Emergency Contact Phone*:
Person's authorized to pick up my child:
Emergency Medical Authorization:
I/we the parent(s)/guardian of this child authorize Good Shepherd Baptist Church to obtain immediate medical care and consents to the hospitalization of, the performance of necessary diagnostic test upon, the use of surgery on, and/or the administration of drugs to my/our child or ward if an emergency occurs when I/we cannot be located immediately. I/we also understand that this agreement covers only those situations that are true emergencies, and only when I/we expect to be contacted immediately. I/we will be responsible for payment of medical care expenses.
Do you agree with the disclaimer:
Y
N
Insurance Company Name:
Insurance Policy Number:
Child's Physician:
Physician's Phone:
Medical History:
(Age)
Asthma:
N/A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Chicken Pox:
N/A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Heart Disorder:
N/A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Measles:
N/A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Rubella:
N/A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Pneumonia:
N/A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Whooping Cough:
N/A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Diptheria:
N/A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Mumps :
N/A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Food Allergies:
Allergies:
Seizures:
Actions to take in case of an emergency (in regard to any of the information indicated above):
For Adult Workers and Parents Staying for Entire Program:
Will you require nursery provision for an infant?
N/A
Yes
No
If so, how many of your children will be in the nursery?
Names of Infants and Toddlers:
• VBS Dates and times are:
• Kickoff: Sunday, July 5th 6-8pm
• VBS: Monday, July 6th through Thursday, July 9th from 6:00 – 9:00 p.m. & Saturday, July 11th from 10am – 1:00 p.m.
• Family Cook-out & Camp-out: Friday, July 10th starting at 6:00 p.m.
• Your children will be playing games throughout the week that may include getting them wet. If you would like to send a towel and a change of clothes for your child that would be great.
• On Family night, the kids will be playing on a water play inflatable, the air bound, and a climbing wall which will be operated two trained operators from the company from which we are renting the wall.
I give my child permission to play on the inflatable water slide, the moon bounce and the climbing wall. I will hold Good Shepherd Baptist Church and all of its representatives harmless from any accidents that may occur using this equipment.
Do you agree with this disclaimer:
Y
N
Comments/Questions